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This form is for adults to refer a young person under 19 years of age for counselling. The young person must live in Newport to be eligible for an appointment.
Young Person's Gender
Has the young person agreed to counselling?
Reason for referral (tick up to 3 as appropriate)
Are there any current or pending police investigations or court proceedings that relate to the child?
Any other services/professionals involved in child’s welfare (select as appropriate)
Does the young person have special educational needs (SEN) or a disability?
This part of the survey uses a table of questions,
Consider your observations of the child over the last two weeks and respond to the following statements below
As the parent (or legal guardian), I have read and understood the Parent Consent Information & Privacy Notice and I agree to my child receiving counselling.