Young People's Counselling Referral Form

Home / Young People’s Counselling Referral Form

In order for you to be added to our waiting list, we need to take some details from you and to ask you some questions. This is so that we can ensure we are the right service for you. Once we receive these details, we will be in touch.

Please note: If you are filling in the form on behalf of someone else, we need their details, not yours.

Young People's Counselling Service Referral Form

Please use this form to refer to our face-to-face or online counselling services for young people.

"*" indicates required fields

Title

Full name*

Email address*

Date of Birth*

Address*

Town*

Home telephone number

Is it OK to leave a message from Buckinghamshire Mind on this number?

Yes

Mobile number*

Is it OK to leave a message from Buckinghamshire Mind on this number?*

Yes

Please select the type of counselling you are interested in*

What is your preferred time for an appointment?*

Mon – Fri (9am to 12noon)

Mon - Fri (12noon to 5pm)

Please note that we can’t guarantee appointments at your preferred time, but we will try our best to accommodate your preference.

What are the three main reasons for your referral?*

How did you hear about our service (please select)?*

Privacy Statement

We need to keep some information about you to give you the right support at Bucks Mind.

When you start a service we need to know things like your name, date of birth, address and phone number so we can get to know you, work with you in the best way and contact you if necessary. We also collect information about your ethnicity, religion and gender which we use to check we are reaching all groups of people in the community.

Other information like your GP or mental health worker and your current health and wellbeing are important so we understand how you are, how we can best support you and who to contact if we are worried about you.

When we complete a support plan with you we may ask you what you like doing and what your goals are so we can help you achieve them. Some people’s stories and photos make lovely case studies and we may ask your permission to share these to show how our services can help people.

We are a confidential service and want you to feel safe and respected. We will always ask you before we share information about you and we will tell you what we are doing and why. Information about you is private which is why we check with you first. If you were to become very unwell or were unable to make your own decisions (we call that lacking capacity) then we may share information if we felt you or someone else may be in danger. This may be with a GP, family member or someone else who supports you to make sure you are safe.

We only keep information if we really need it and we look after it carefully.

If you would like to read our full Privacy Policy, please click on the button below.

Back to Counselling for Young People