Referral Form

Our service is available age 13 to 25th birthday (last referral age 24th birthday) if you live, work or are being educated in St Albans and District. We are open 10am till 7pm Monday - Thursday, 10am till 5pm on Fridays (we are not currently open on weekends). Youth Talk offers one to one counselling and group therapy.

Please note that our service is self-referral only. As such, we will then call to get any further information and set up an initial consultation when one is available, this could be face-to-face or via Zoom. Please check for any missed calls, texts and emails. This form MUST be completed by the young person.

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Indeterminate

Prefer not to say

Ethnicity:*

Religious or Belief Affiliation:*

Sexuality:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Email:*

Mobile Phone Number:*

Home Phone Number:

The main method of contact is email - please remember to check these

Permission to send SMS?:*

Yes

No

Permission to leave voicemail on mobile phone?:*

Yes

No

Permission to leave voicemail on home phone?:

Yes

No

GP name (if known):

GP Practice Name:*

Are you?:

If working or other, please specify:

School/college details:

If other, please specify:

Reason why you would like to see a counsellor:*

Have you been to Youth Talk before?:*

Yes

No

Do you have any links to Youth Talk i.e. anyone who works here/or has used the service?:*

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, Mondays/Fridays). Please note the more flexible you can be with times the quicker we might be able to see you:*

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 form 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

Permission to Contact

GP Details

Further Details