MYMUP

An asterisk (*) indicates an essential piece of information in the form below. Please complete these and as many other sections as you can. Thank you

Consent

Has your client consented to this referral? *

Yes No

If yes, please make sure your client is aware that you’ve now made the referral, and that we will contact them directly using the contact details you provide.

If no, please get their consent before proceeding, as we are unable to progress the referral unless consent is confirmed.

Thank you

Please answer all 3 questions first

Is your client the parent or carer of a child aged 5 or under? *

Yes No

Is your client pregnant? *

Yes No

Is your client the partner of someone who is pregnant? *

Yes No

Client details

Preferred First Name *

Preferred Last Name *

Address *
Postcode Lookup

Date of Birth *

Consent to contact* At different stages we will need to contact your client by phone and email if possible, and perhaps to leave a voicemail if necessary. When your client is contacted later by one of our counsellors, they may need to text (SMS) your client. So please help us to help your client – get their consent to tick as many options below as you can. (We’ve ticked phone and email already because these are so helpful for contact, but you can of course untick them if you need to.)

Phone number *

Email Address * (Or if your client does not have one, or does not want us to email them, then write ‘no’)

Gender

Ethnicity

Do they have a disability?

Yes No Not Sure

How many children under 18 are they responsible for looking after? *

GP practice name *

Or 'Don't know' or 'Not registered' - but please note that your client will need to be registered with a Leeds GP and inform us of this, before any counselling can begin.

Safeguarding

Do they have a social worker? *

Yes No Not Sure

Is there a Child Protection Plan in place? *

Yes No Not Sure

Referral details

Is your client looking for couples counselling? *

Yes No

Brief details of why client needs counselling support

Your name *

Your role/job title *

Your phone number *

Your email address *

Your organisation/base *

What is your involvement with this client? *

How did you hear about us?

Counselling approach/location

Our service is open to all parents/carers of 0-5s in the Leeds area, as well as those who are pregnant, and their partners.

Your client will be placed on a waiting list to be seen by any of our team of qualified and accredited counsellors.

Most counselling is still provided remotely, by phone or video call. We are offering a few face-to-face appointments in certain children’s centres where it is safe and practical to do so. We will continue to offer the option of phone/video appointments for those who find this more accessible.

You can tell us your client's preference/s here, in relation to remote or face-to-face support. However, please be aware that at times we may only able to offer remote support, and that this might be the quickest way for your client to access counselling.

Your client’s first choice of counselling approach/location would be:

Face to face - at a children's centre in the area/s specified below
Remote - by phone or video call
No Preference

Client privacy

Our privacy policy provides more details about how we store the information that you share with us on behalf of your client.

Welcome Children's Centre Counselling Service

Consent

Please answer all 3 questions first

Client details

Safeguarding

Referral details

Counselling approach/location

Client privacy