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

Location

Some of our services are offered nationwide. These can be accessed from areas across the country we currently work from. Or if you cannot see your area, please select "other" and type your (or clients) local authority.

Local authority area:(Required)

A-Z descending. Click to expand drop down.

Other:

Please type

Important Update

Please note that we do not handle enquiries onto any Behaviour Change programmes for Young People in Tameside.

Refer a child or young person. Click here.

Important Update

Please note that we do not handle enquiries for Encouraging Healthy Relationships, Respect Young People's Programme, and Counselling for Children and Young People in Salford. These should be made using the "Harbour updated referral form Sep25" - found on the Safe in Salford website.

Refer a child or young person. Click here.

What service are you referring to?(Required)

We use this phrase to help us direct enquiries to the right team. It just means you are submitting this form to book a 'person' into TLC services. This could be your client, yourself or a child you are the parent/guardian of. We will refer to this throughout as 'Person'.

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.

Name of Organisation:(Required)

If council please specify department and Children/Adults

Your Phone Number:(Required)

Your Work Email:(Required)

Young Person

Schools Emotional Wellbeing Services

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

We collect both sets of details, but need confirmation as to who requires support.

Partnered Schools

School/College the pupil attends:(Required)

Background Information

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

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?

This field is hidden when viewing the form

Person's Details

Please enter information below on the person accessing TLC. This could be your client, yourself or a child you are the parent/guardian of. We will refer to this throughout as 'Person'.

Person's Details

Please enter information below on the person accessing TLC. This could be your client, yourself or a child you are the parent/guardian of. We will refer to this throughout as 'Person'.

Contact Email:

For confidential services, please ensure only you have access this to email address.

Contact Number:(Required)

Date of Birth:(Required)

Gender:(Required)

Is English a first language:(Required)

Is it safe to leave a message for this Person on the contact number supplied:(Required)

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:

Please include any relevant criminal, safeguarding and risk information, if known.

Please could you briefly describe what aspects of neurodiversity the Person requires 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.

Has the Person consented to the referral:(Required)

Date of Caution

Crime Reference Number:(Required)

Type of Caution:(Required)

Date of Offence

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:

Intervention to be completed by(Required)

Contact Safety

Additional information

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

Service delivery information

Please note in-person may not always be available.

Session availability(Required)

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.

Who is the additional party:(Required)

Other Party Date of Birth:(Required)

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

Submission

How did you hear about TLC?(Required)

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Book or Refer

Location

Housing Services

Referrer Details

Young Person

Schools Emotional Wellbeing Services

Partnered Schools

Background Information

Person's Details

Person's Details

Cautioning and Relationship Abuse Service (CARA)

Contact Safety

Additional information

Service delivery information

Other Party Information

Mediation

Submission

How we handle referrals

More questions?

Where to next?

Before Your Session

Payments

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