Refer to TCA Counselling in Schools

Please complete the form below to refer a child/young person for counselling.

Tayside Referral - Counseling

Name of School

Required

Name of Pupil

Required

DOB

Required

Class/Year Group

Required

Gender

Required

Ethnicity

Required

ASN/Disability

Required

Named Person for the Child/Young Person

Name of Referrer (if different)

Referrer Email Address

Date of Referral

Privacy Notice Signed and Returned

Staged Level of Intervention

C/YP Plan: Y/N

Young Carer: Y/N

LAC: Y/N

CP Registered: Y/N

Attendance Rate at Time of Referral

FME: Y/N

SIMD 1/2: Y/N

Any other agencies/partners supporting?

Has multi-agency discussion taken place re referral? Y/N

Why is the child/young person being referred for counselling

Are parent/carers aware of the referral: Y/N

What are the views of the parent/carers?

What are the views of the C/YP?

Please note and protective factors that you are aware of (eg supportive parents/peer group/social/emotional skills)

Please note any risk factors that you are aware of (e.g exam stress/absenteeism/relationships)

Any other information you think would be useful for the counselor to be aware of?

If the YP (aged 12+) is willing to be contacted by mobile phone/email by the counselor, please provide details

URGENT: Y/N

Email enquiries@alcoholtayside.com for confidential advice