Young Person Self-Referral Application Form - Elliott Holmes Memorial Fund

Phone

This field is for validation purposes and should be left unchanged.

Use this form if you are a young person seeking help. This form MUST ONLY be completed by the Young Person. Referrals from other parties will be rejected. Please note: we do not have the capacity to take on conditions related to eating disorders or Young People who have been adopted. We DO NOT offer counselling at your school or home.

Have you tried to seek help using the links on our 'Online support' page? (under the main menu heading counselling)(Required)
There is lots of useful advice covering common issues which we hope you will find useful

Type of Referral(Required)

Please confirm the following:

Please read the counsellors profiles before proceeding. Subject to availability, we will endeavour to allocate you your chosen counsellor once selected in the 'Your counselling choices' section below. If you're not sure which counsellor(s) to choose then select based on location and how they deliver their counselling e.g. Face-to-face, Zoom, WhatsApp.(Required)
I am a YOUNG PERSON completing this form myself (tick box)
I have read the Young People's Expectations (tick box)
I have read and accept your Conditions of Funding (tick box)
I have read and accept your GDPR and Privacy Statement (tick box)
I am NOT adopted. (For support please visit Barnardos Adoption Support) (tick box)
Please read the counsellors profiles before proceeding. Subject to availability, we will endeavour to allocate you your chosen counsellor once selected in the 'Your counselling choices' section below. If you're not sure which counsellor(s) to choose then select based on location and how they deliver their counselling e.g. Face-to-face, Zoom, WhatsApp.

Personal details

First name(Required)

Surname(Required)

Gender(Required)

Date of Birth(Required)
DD slash MM slash YYYY

Age(Required)

Ethnicity(Required)

Home Address(Required)

Your full home postcode(Required)
PLEASE USE CAPS and style like this: DA12 4YG Your address will be kept confidential.

Mobile number (start with 07, no spaces) 11 digits, please check or we cannot contact you!!(Required)
This is a SELF_REFERRAL and therefore must be YOUR OWN personal mobile (NOT your parents or guardian). We will use this number to contact you, NOT YOUR PARENTS.

Email (please provide if you have one - see note below))(Required)
If you do not hear from us via text within a few days it will be because your mobile number has been entered incorrectly. Please provide an email if you have one so we can still contact you!

Is a parent or guardian aware you are contacting us?(Required)
Your parent or guardian DOES NOT need to know for you to acccess support. Your referral will remain confidential unless a serious safeguarding issue becomes apparent at anytime during your counselling sessions.

Preferred method of contact (please select)(Required)
This is how your counsellor will make contact with you in the first instance.

If telephone, can we leave a voicemail (please select)(Required)

Emergency contact details

Emergency Contact Name(Required)
EHMF and/or your counsellor will need to have the details of someone (over the age of 18) that can be contacted in case an emergency arises. This does not need to be a parent or carer but it does need to be someone who knows you well. This could be a friend, family member or a school teacher. The counsellor can explain this more during the first session.

Emergency Contact mobile number (start with 07, no spaces, 11 digits, please check)(Required)
This must be the Emergency Contact's mobile number, NOT your own. They will only be contacted if an emergency arises. Your referral will be treated in confidence. If you enter your own number, the referral will be rejected.

Emergency Contact's relationship to you(Required)

School information

This information is for data purposes only and will NOT be shared with your school

School attended(Required)

If other, please specify

School year(Required)

Please Note: All St.George's School referrals are currently on hold. Please DO NOT submit this form. Refer back to your school pastoral support for further assistance. If you are in crisis, click on the red tab to the left of this page for emergency numbers.

Is your school aware you are struggling with your mental health?(Required)

What support have you received from your school(Required)

Medical details

How long have you been struggling with your mental health?(Required)

Have you received counselling before(Required)

Are you currently receiving counselling?(Required)

Have you been in contact with any health care professional?(Required)

Please provide names and contact details

What support have you received from your GP?

Are you on CAHMS or other waiting list? (For data purposes only)(Required)

How long have you been on the waiting list? (For data purposes only)(Required)

IMPORTANT REMINDER - We are not a crisis service. If you need urgent help, please click on the red NEED EMERGENCY HELP tab located on the left side of this page and use the contact information provided

Your counselling choices

Please note, all face-to-face counselling sessions are delivered on the counsellor's premises. We DO NOT offer counselling on school premises. Please ensure you select a counsellor in a location where you can make your own arrangements for transport.

1st Choice counsellor(Required)
(see Counsellors page)*

2nd Choice counsellor(Required)
(must be different than 1st choice)*

Type of counselling preferred(Required)
Please check your chosen counsellor offers this type of counselling. You will need to make your own travel arrangements for face-to-face appointments.

Please indicate availability by checking the box
09:00 - 16:00 Monday to Friday
16:00 - 20:00 Monday to Friday
Weekends
Please note: Your availability may affect the choice of counsellor you are offered

Please let us know why you would like counselling(Required)

Tick any boxes which may relate to your situation
Abuse
Addiction (drugs, alcohol or other)
Anger
Anxiety
Bullying
Depression
Exam stress
Family and home life
Friendships
Grief and loss
Identity issues
Intrusive thoughts
Loneliness
Low self-esteem
Neurodiversity (ADHD, Autism, Dyslexia)
OCD
Panic attacks
Relationships
Self-harm
Sleep problems
Social media impact
Suicidal feelings
Trauma/PTSD
Other concerns

Other comments you may wish to add

We’d love to understand how technology is fitting into your daily routine. On average, how many hours do you think you spend on your phone or other devices each day? This helps us understand what’s going on in your day-to-day life and how we can best support you.(Required)

Less than 3 hours a day

3 to 5 hours a day

5 to 7 hours a day

More than 7 hours a day

Marketing

How did you hear about us?(Required)

If other, please specify

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To be actioned(Required)

This field is hidden when viewing the form

Remaining budget(Required)

VERY IMPORTANT! Before you click submit, please double check your mobile number. Make sure it has 11 digits, starts with 07 and is correct. The same goes for the emergency number you have given us. Without the correct number you will not hear from us!

Declaration(Required)
I confirm the information provided is accurate to the best of my knowledge. (tick box)

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