Step by Step Counselling Referral Form

Counselling gives you a safe place to be heard and it is completely confidential.

Our free counselling service is based on building a trusting relationship with you. It can help you talk about your experiences and worries and how to manage them in a supportive way. Our counsellors are trained to listen carefully and thoughtfully to you, without judgement.

We can accept self-referrals for young people aged 11-25 with a GP in Surrey.

We cover Guildford, Surrey Heath, Waverley. Our service is free and confidential. More information can be found at:

https://www.stepbystep.org.uk/young-people/mental-health/counselling/

We can also accept self-referrals for young people aged 11-18 with a GP in Hampshire, here: https://www.hyapartners.org.uk/portal

We are not a crisis service. If you are concerned about the immediate safety of you or someone else then call 999 for emergency services or visit your local A&E.

If you are in need of help and it is not an emergency we would recommend contacting your GP, NHS 111 or the following services:

Samaritans - 116 123 - jo@samaritans.org - https://www.samaritans.org/

Papyrus - 0800 068 41 41 - pat@papyrus-uk.org - https://papyrus-uk.org/

Young Persons Safe Haven (Aldershot) - https://nolimitshelp.org.uk/get-help/health-wellbeing/safe-havens/

CYP Haven Surrey - https://www.cyphaven.net/

Surrey Crisis Line - 0800 915 4644

If you live in Hampshire and are under 18, you can access support by making a referral to Hampshire Youth Access - https://www.hyapartners.org.uk/portal

Please tell us if the following applies to you or the young person wishing to accessing support

I am/the young person is aged 11-25 with a GP in Surrey I am/the young person is aged 11-18 with a GP in HampshireNone of the above apply to me/the young person

You are not eligible to use this form:

Our service is only available to young people aged 11-25 registered with a GP in Surrey. If you are seeking support we would recommend the following:

Contacting our Launch Service
Contacting your GP
Visit the Anna Freud Wellbeing Directory

You are not eligible to use this form:

To access our service if you have a GP in Hampshire:

Complete the referral form on the Hampshire Youth Access website; or
Contact our Launch Service

For any queries please call us on 01252 346120 or use the webchat service on our website.

Referrer Details

Please tell us who is making the referral

Please make sure you have gained the appropriate consent before making this referral.

Relationship with child

Other relationship

Referrer name

Organisation

Referrer contact number

Referrer email

If you are a professional working with a child or young person please outline your relationship with them and what work you have completed

Child/Young Person Details

First Name

Last Name

Date of Birth

Sex

Ethnicity

NHS Number (if known)

Format required is 3 numbers, hyphen, 3 numbers, hyphen, then 4 numbers (3-3-4) e.g. 123-123-1234

Street
(including number/name)

Town/City

County

Post code

Mobile Phone

GP Surgery

Education setting: Please tell us which school/education provider you/the young person attends

Parent/Guardian Details

Please provide contact details of person with parental responsibility. We will only contact parents/guardians with consent.

Parent/Guardian Name

Parent/Guardian Contact Number

Parent/Guardian email

Is the child/young person happy for parents/guardians to be contacted?

YesNo

Reason for Referral

In the section below, please outline the reason for making the referral. Please provide as much detail as possible.

Please tell us the reason for referral

Please tell us anything important that we should consider about your referral

Consent

We promise to respect any personal data you share with us and keep it safe. We aim to be clear when we collect your data about how it will be used, and not to do anything you would not reasonably expect. Our privacy policy can be accessed here.

Your data may be shared with or stored on NHS platforms for the benefit of the care you receive via the NHS, Mindworks or charities working on behalf of Mindworks. You can read the Mindworks privacy statement on the Mindworks Surrey website.

If you are unable to accept our privacy policy, we will be unable to process your referral. If you have any questions about this please contact us by visiting our website or by calling 01252 346120.

Please confirm you have read and understood our privacy policy

I agree to Step by Step processing my information.

Step By Step, 36 Crimea Road, Aldershot, Hampshire, GU11 1UD

01252 346120

counselling@stepbystep.org.uk