Parenting 2000 Therapeutic Services Referral (Child aged 15 years and under) Please complete the below form to refer a child (15 years and under) for counselling/therapy with Parenting 2000 Therapeutic Services. Referrer Details Name of referrer(required) Organisation (if self referral, type the word self)(required) Telephone number(required) Email address(required) If self referral, where did you hear about our services? Child’s Details First name(required) Last name(required) Address(required) Postcode(required) Gender(required) Date of birth(required) Ethnicity Asian or British Asia – Indian Asian or British Asia – Pakistani Asian or British Asia – Bangladeshi Asian or British Asia – Any other Asian background Black or Black British – Caribbean Black or Black British – African Black or Black British – Any other Black background Mixed – White and Black Caribbean Mixed – White and Black African Mixed – White and Black Any other Mixed background White – British White – Irish White – Any other White background Chinese Any other ethnic group Landline telephone number Mobile telephone number(required) Can we leave a voicemail message/text? Yes No Email address(required) Parent/Guardian’s Details First name(required) Last name(required) Relationship to client(required) Address(required) Postcode(required) Landline telephone number Mobile telephone number(required) Can we leave a voicemail message/text? Yes No Email address(required) Referral Information Reason for referral(required) Other agencies involved Thank you for completing the referral form. Before sending us this referral, please read the following on how the information you have given is processed and stored: All the information provided on this form, including any further follow-up information, is kept safe and securely.Parenting 2000 works in partnership in Sefton with other psychological mental health organisations to provide an “Improving Access to Psychological Therapies” (IAPT) – Children & Young People service in the borough.Client records from Parenting 2000 and the IAPT Partners are stored and shared on a secure single cloud based database system.The IAPT partnership staff who have accessed to your records are bound by the strictest confidential protocols. By sending us this completed referral, you are confirming that you agree to the above privacy/data statement. We aim to be in contact within 72 hours to acknowledge receipt and to ask any further related follow-up questions. We will not add your referral to our waiting list until follow up information has been given. Submit Δ Share this:FacebookTwitterMoreSkypeWhatsAppEmailPrintLike this:Like Loading...
Parenting 2000 