Compassion Counselling

Parent details

Referrals for children or young people under 16 years old must be made by someone with parental responsibility who can give consent on behalf of the child and act as their point of contact.

Title

Parent first name

Parent last name

Telephone numberWe will use this to contact you, so please enter a valid phone number - preferably mobile

EmailWe will use this to contact you, so please enter a valid email address

Parental consent

I confirm that I hold parental responsibility for my child named below and I give my consent for my child to be referred and engage with Compassion Counselling Service. I consent for my & my child's personal information submitted in this referral to be gathered, processed, and stored in accordance with the Data Protection Act (2018).

Tick this box to confirm

Completing the rest of this form

Please complete the remainder of the form with your child, answering the questions on their behalf. Anywhere the form says "you" or "your", assume that it means your child.

Online application

Step 1 of 5

Completing the rest of this form