About the client

This referral form helps us understand who we are supporting and what matters most right now. There are no right or wrong answers — tell us as much or as little as feels useful.

Client Name

Preferred Pronouns

Client DOB

Referrer and contact details

So we know who to reply to.

Name of Referrer and Relationship to Client

Phone Number

Email Address

Address, school and GP

Current School (if applicable)

Home Address

GP Name and Address

Current support

Other services / professionals currently involved (SLT, OT, Physio, CDC, RISE NI, CAMHS)

Any current diagnosis(es)?

Main concerns

Please share as much detail as you feel is helpful.

Main Concerns:

What areas do they find tricky? What causes them to experience anxiety / stress / low mood / emotional overwhelm and what does this look like?

Strengths and interests

What are your child’s/young person’s strengths/skills and interests? What do they enjoy doing the most/what motivates them?

Anything else

Additional relevant information:

Can you commit to an initial block of six sessions:

Yes

No

Review your answers

Please check everything below before submitting. You can go back and change any section — nothing is lost.

Form submitted

Your reference

Psychology Intervention Referral Form