Youth Counselling Referral Form

Please only complete this form if :

you are aged 16-18 years and would like to refer yourself for counselling,
or you have parental responsibility for the child/young person aged 4-18 years and their agreement to participate,
and the child/young person lives in the Harrogate area (within a 20 mile radius around Harrogate).

Step 1 of 4

Who is completing this form?
Are you:*
- A young person aged 14+, completing this form for yourself
- A parent or carer referring a young person aged between 4-18 to us
About the young person
Your name*
First Last
Young person's name*
First Last
Your address*
Street Address Address Line 2 City Postcode
Young person's address*
Street Address Address Line 2 City Postcode
Your date of birth*

Day
Month
Year
Young person's date of birth*

Day
Month
Year
Your age*
Young person's age*
Your gender*
What is your preferred pronoun?
Young person's gender*
What is the young person's preferred pronoun?
Your email address*
Young person's email address
Mobile Number*
OK to leave voicemail messages on this mobile number?
- Yes
- No
Young person's mobile number
OK to leave voicemail messages on young person's mobile?
- Yes
- No

About your parent or carer
Please provide the name and contact details of a parent/carer who has agreed to:
- Receive contact from Wellspring by phone/email regarding setting up your counselling appointments
- Receive contact from Wellspring by phone/email regarding any safeguarding concerns
- Pay for sessions
Their name*
First Last
Their email address*
Their telephone number*
About the person completing this form
Your name*
First Last
Your relationship to the child/young person*
Your Address*
Same as young person's

Street Address Address Line 2 City Postcode
Your mobile or landline number*
OK to leave voicemail messages on this number?
- Yes
- No
An additional number we can contact you on
(Optional)
OK to leave voicemail messages on this number?
- Yes
- No
Your email address*

Wellspring House

78 High Street, Starbeck
Harrogate, HG2 7LW

01423 881 881

Email Us

Opening times

Monday 9am - 8.30pm
Tuesday 9am - 8.30pm
Wednesday 9am - 8.30pm
Thursday 9am - 8.30pm
Friday 9am - 5.00pm
Saturday & Sunday Closed

We work to the British Association for Counselling and Psychotherapy (BACP) Ethical Framework for Good Practice and the Association of Christian Counsellors (ACC) Code of Ethics.

Wellspring is an Affiliated Organisation number AT 326 of the Association of Christian Counsellors (ACC) and a partner in the Route One VCS Partnership.

We are a Registered Charity, number 1100420, and a Company limited by guarantee, Number 4728609.

Quick links

Contact information

Wellspring House

78 High Street, Starbeck
Harrogate, HG2 7LW

Step 1 of 4

Who is completing this form?

About the young person

About your parent or carer

About the person completing this form

Counselling

When are you available to come for counselling?

When is your child/young person available to come for counselling?

Medical history

Wellspring House

01423 881 881

Email Us

Opening times

Quick links

Contact information

Wellspring House

01423 881 881

Email Us