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Book or Refer

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Cancellation Policies

Are you professional referring someone?(Required)

Yes

Professional Referrals

Please ensure you read any relevant service criteria before completing this form.

Professionals: What service are you referring to?(Required)

Services

What service are you referring to?(Required)

Important Update

Please note we are no longer accepting self-funded counselling enquiries. These are now available through our subsidiary Now You're Talking. nowyouretalkingtherapy.co.uk

Client's Location

Local Authority the client lives in(Required)

Local Authority the client for CARA lives in:(Required)

Local Authority the client for Cancer Support lives in:(Required)

Local Authority the client for Partner Schools lives in:(Required)

Local Authority the client for SOAR programme lives in:(Required)

Local Authority the client for Respect Young People lives in:(Required)

Local Authority the client for Young People Counselling lives in:(Required)

Local Authority the client for Vernon Robert Bowmer Charitable Trust Counselling lives in:(Required)

Local Authority the client for North Worcestershire Counselling lives in:(Required)

Local Authority the client for Encouraging Healthy Relationships lives in:(Required)

Local Authority the client for Adult Early Intervention programme lives in:(Required)

Local Authority the client for Aspiring to Change lives in:(Required)

Local Authority the client for Bridging to Change lives in(Required)

Local Authority the client for Adult Prevention Order lives in:(Required)

Local Authority the client for Wigan Rapid Response lives in:(Required)

Local Authority the client for Nottinghamshire Counselling lives in:(Required)

Local Authority the client for Bradford Counselling lives in:(Required)

Local Authority the client for Herefordshire Counselling lives in:(Required)

Local Authority the client for Bradford and Leeds Counselling lives in:(Required)

Local Authority the client for East Anglia Counselling lives in:(Required)

Local Authority the client for Worcestershire and Herefordshire Counselling lives in:(Required)

Local Authority the client for London Counselling lives in:(Required)

Local Authority the client for Chesterfield Counselling lives in:(Required)

Local Authority the client for Essex Counselling lives in:(Required)

Local Authority the client for Derbyshire Counselling lives in:(Required)

Local Authority the client for Locala Counselling lives in:(Required)

Tameside Referrals:

Important Update

Please note that we do not accept Domestic Abuse Referrals Young People in Tameside.

Refer a child or young person. Click here.

Salford Referrals:

Important Update

Please note that we do not accept Domestic Abuse Referrals or Counselling Self-Referrals for Young People in Salford.

Refer a child or young person. Click here.

Housing Services

Housing Provider:(Required)

What best describes the client:(Required)

Jigsaw area you are referring from?(Required)

What Jigsaw Housing Team are you referring from?(Required)

Referrer Details

Please enter your details below so we can contact you about this if necessary

Referrer Name:(Required)

First Last

Name of Organisation:(Required)

If council please specify department and Children/Adults

Your Phone Number:(Required)

Your Email:(Required)

Young Person's Details

Young Person's Name:(Required)

First Last

Young Person's Gender:(Required)

Young Person's Date of Birth:(Required)

DD slash MM slash YYYY

Young Person's Address:(Required)

Street Address Town / City Post Code

Is English the Person's first language:(Required)

Does the Young Person have any access or communication difficulties we need to be aware of? If so please describe:

Please describe what the young person requires support with and any other information you feel is relevant (including risk and safeguarding information):(Required)

Has the young person been made aware of this referral:(Required)

Partnered Schools

School/College the pupil attends:(Required)

Education details:(Required)

Listed at a school / college

Home-schooled

NEET (Not in employment, education or training)

School/ College address:(Required)

Please use the full school name and address.

School Name Address Borough / City Post Code

Background Information

We use this information to triage the young person to the most suitable support service.

Is the young person a Looked After Child?(Required)

Yes

Unsure

GP of the child / young person, if known:

Please describe what services are already provided to the child or family:

Details of any education healthcare plan:

Details of presenting problem:

Please give details about observed behaviours such as mood, emotions, communication, appetite, and sleep.

How long has this difficulty been present?

Is this difficulty present in all areas?

e.g. home, school and social settings

Social History:

Please include details of any relevant family circumstance, life events, bereavement, domestic abuse, parental mental health, learning needs or disability, ill health

Any known risk factors to the child and family:

e.g. violence, substance misuse

Please describe how you believe this referral will benefit this child or young person and what do you believe would be the most appropriate focus of our work?(Required)

What would the child or young person want us to work on with them?

Your Details

Please enter your information below to make a referral

Your Name:(Required)

First Last

Your Gender:(Required)

Your Date of Birth:(Required)

DD slash MM slash YYYY

Your Address:(Required)

Street Address Address Line 2 City Post Code

Your Phone Number:(Required)

Your Email:(Required)

We run many confidential services, please ensure only you have access this to email address.

Please briefly describe what you require support with and any other information you feel is relevant:(Required)

Please could you briefly describe what aspects of neurodiversity you require support with(Required)

eg: Social & Communication, Sensory Differences, Routine & Structure

Are you able to access TLC services Online?(Required)

Yes

Person's Details

Please enter information about the person you are referring below.

Person's Name:(Required)

First Last

Address:(Required)

Street Address Address Line 2 City Post Code

Person's Email:

Person's Phone Number:(Required)

Person's Date of Birth:(Required)

DD slash MM slash YYYY

Person's Gender:(Required)

Is English the Person's first language:(Required)

Has the Person consented to the referral:(Required)

Is it safe to leave a message for this Person:(Required)

What is the Person's preferred method of contact:(Required)

Phone Call

Text

Does the Person have any access or communication difficulties we need to be aware of? If so please describe:

Please describe what the person requires support with (including any relevant criminal, safeguarding and risk information):(Required)

Please could you briefly describe what aspects of neurodiversity you require support with(Required)

eg: Social & Communication, Sensory Differences, Routine & Structure

Cautioning and Relationship Abuse Service (CARA)

In this section you will provide specific information for this service. Note that victims should be consulted and aware of the referrals as they will be contacted as part of the programme.

Date of Caution

DD slash MM slash YYYY

Crime Reference Number:(Required)

Type of Caution:(Required)

Type of Offence:

Details of Offence:

Borough or District the offence took place:(Required)

Type of Delivery Agreed:

If CTI, please provide reason:

Please provide any details around risk to self:

Please provide any details around risk to others:

Please provide any details around risk from others:

Contact Safety

Is it safe to contact/leave a message?(Required)

Safe to send text messages

Safe to leave voice mails

Not safe to leave messages

Domestic Abuse Service

This information is for a domestic abuse service referral. For perpetrator programmes - there must be an acceptance of their actions/abuse and there must be a willingness to change.

Does the Person understand what the programme is about:(Required)

Are they living with their perpetrator or victim?(Required)

Is the Person at risk of being harmed or present a risk of harming others? Please provide details:(Required)

Is there an ongoing investigation for domestic abuse? Is the person currently on bail for a domestic abuse offence(Required)

Are there any pending court dates for this offence:(Required)

Is the person a risk to professionals?(Required)

Additional information

Is the Person involved in any of the following: (tick to answer yes)(Required)

Family Court

Criminal Court

Current Criminal Investigation

Early Help

Child in Need

Child Protection

None of the above

Please describe what is in place for the client:(Required)

Service delivery information

This information is required for a referral. Please note in-person may not always be available.

Preferred method of service delivery:(Required)

Online Video Call

Phone

In Person

Other Party Information

In order to process this referral, we will need additional details to ensure we can work in a safe way with all those involved. If you're referring an adult, please provide information on the former/current partner. If you're referring a child, please provide information on the child's parent/guardian. Domestic abuse perpetrator referrals please add victim details here. Family Mediation please add ex partner details here.

Is the Other Party Aware of the Referral?(Required)

Yes

Who is the additional party:(Required)

Other Party Name:(Required)

First Last

Other Party Address:(Required)

Street Address Address Line 2 City Post Code

Other Party Date of Birth:(Required)

DD slash MM slash YYYY

Other Party Email:

Other Party Phone Number:(Required)

Are there any other contact details we need to be aware of? (i.e. any additional agencies)(Required)

This can include school or social worker contact details

Mediation

Are there any orders in place preventing you from direct contact with the other party?(Required)

Yes

Are there any orders in place preventing the person you are referring from direct contact with the other party?(Required)

Yes

Why does the person require Mediation:(Required)

Children

Property and Financial matters

Both

Other

Where did you hear about us?(Required)

Where did they hear about us?(Required)

Schools Emotional Wellbeing Services

Are you referring in an Adult or Young Person?(Required)

Counselling: Employer Partner

Which partner company are you from?(Required)

Recovery Counselling Referral Information

What is the person's history with alcohol or substance use? (please include whether this is current or historic and what additional support they are accessing). Please note counselling is not suitable for people who are currently in active addiction.(Required)

Please provide some additional information about your history with alcohol or substance use. (include whether this is current or historic and what additional support you are accessing). Please note counselling is not suitable for people who are currently in active addiction.(Required)

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How we handle referrals

For professionals - more details about how we handle information and process referrals.

Find out more

Where to next?

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Book or Refer

Professional Referrals

Services

Client's Location

Tameside Referrals:

Salford Referrals:

Housing Services

Referrer Details

Young Person's Details

Partnered Schools

Background Information

Your Details

Person's Details

Cautioning and Relationship Abuse Service (CARA)

Contact Safety

Domestic Abuse Service

Additional information

Service delivery information

Other Party Information

Mediation

Schools Emotional Wellbeing Services

Counselling: Employer Partner

Recovery Counselling Referral Information

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How we handle referrals

More questions?

Where to next?

Before Your Session

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