Referral Form

Our service is available to anyone between 13-25 years of age living, going to school or working in St Albans and District (ie including Harpenden, Wheathampstead, Redbourn, London Colney, Park Street, Colney Heath etc). Please note that our service is self-referral only.

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Indeterminate

Prefer not to say

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Email:*

Mobile Phone Number:*

Permission to leave voicemail?:

Yes

No

Permission to send SMS?:

Yes

No

Home Phone Number:

Permission to leave voicemail?:

Yes

No

Ethnicity:*

GP name (if known):

GP Practice Name:*

Are you?:

If you are in school, please specify:

If other, please specify:

Reason why you would like to see a counsellor:*

Have you been to Youth Talk before?:*

Yes

No

Have you had any other counselling or help before?:*

Yes

No

How did you hear about YT?:*

What is your availability for counselling? (Days/times?):*

In order to provide our service we need to hold some details about you. Information about our data policy is available on our website and it is important you understand this. By submitting this from you are agreeing to Youth Talk holding your information and our data policy.

Please tick here:*

Yes I agree

Please complete the captcha

Self Referral Form

Personal Details

GP Details

Further Details