Referral Form

Type of Support Required

I am looking for: *

One-to-one counselling for 18 years to 25 year olds

Private counselling (£55/session)

LGBTQ+ group support for 9 to 18 year olds

BeeHIVe (HIV and LGBTQ support/counselling for over 18s)

General advice (Practical support such as housing, benefits, employment, education etc)

Chadd/Top Church referrals

Client title *

Client first name *

Client last name *

Gender *

Date of birth *

Address Line 1 *

Address Line 2

Town/City *

County

Postcode *

Is is okay to write to you at this address? *

Yes

No

NHS number (note you can find this from any GP/hospital letters or you can contact your GP) *

Where would you prefer to be seen for your counselling? *

Face-to-Face Dudley branch (Note that face to face sessions currently have a huge waiting list)

Face-to-Face Stourbridge branch (Note that face to face sessions currently have a huge waiting list)

Telephone counselling

Video counselling (via Zoom)

Have you been to the What Centre previously? *

Yes

No

What is the best contact number to get in touch with you? (Please provide more than one number if possible)

Home Number

Permission to leave voicemail on home number

Yes

No

Mobile Number

Permission to leave voicemail on mobile number

Yes

No

Permission to send SMS?

Yes

No

Who may we speak to?*

What is your email address?

What day(s) and time(s) are you available for an appointment? (only for counselling and advice)*

Can you tell us briefly why you would like to refer yourself?*

Can you also tell us if you have previously/currently are:

Any additional needs (eg. language or disability issues?)

Are you responsible for the care of anyone?

Yes

No

Do you have a Child In Need plan or a Child Protection Plan?*

Yes

No

Do you receive Early Help from a Family Centre or School/Health?*

Yes

No

Which one best describes your current situation?

Name of school/college/training provider

What is your ethnicity?*

Who were you referred by?*

Other?

What is your GP practice? (Note that if you are interested in the 13-25 counselling, your GP has to be on the list provided to be eligible) *

I have read about The What? Centre's data collection system and agree to the fair and lawful processing of personal information for the purpose of analysis and research in line with the GDPR 2018 and Data Protection Bill 2018.

Yes

I understand that the researchers using data collected will NOT have access to any personal data provided (eg. name, address, DOB) which may make the information identifiable to me in anyway or anything that is written or reported about the research.

Yes

The What Centre is a charity which receives funding in order to provide services. At times, funders may require us to pass on the name, address and DOB of young people using the service they fund. I confirm that this can be passed to the funding organisation to confirm that the young person is attending counselling at the Centre.

Yes

I understand that the What Centre will not give any details of what any young person speaks to us about in any of the sessions to anyone, including funders without explicit permissions (or where there are limits to confidentiality)

Yes

I understand that this data is not currently shown on medical records, though this could change in line with data collection requirements for Health England

Yes

Please complete the captcha

Referral Form

Type of Support Required

Personal Information

Reason for referral

Current situation

Monitoring

Referral information

GDPR