Who This Form Is For

This form is for Children & Families Social Work referrals requesting access to supervised adult (18+) student counsellor support at A Positive Start CIC .

Section 1: Referrer Details

Name(Required)

Section 2: Client Details

Client Name(Required)
MM slash DD slash YYYY
Preferred Contact Method(Required)
Safe to leave voicemail?(Required)

Section 3: Consent

Has the client given informed consent for this referral?(Required)
Client understands this referral is for student counsellor support where suitable(Required)

Section 4: Reason for Referral

Section 5: Risk & Suitability Screening

Is the client currently experiencing: (Tick All that Apply)(Required)
Are you aware of any current involvement from statutory mental health services?(Required)

Section 6: Practical Information

Preferred session format

Thank you for your referral. Referrals are reviewed to determine suitability for student counsellor placement support. Where student provision is not appropriate or available, we will advise on alternative options including our reduced partner-rate counselling pathway.

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