Progeny Counselling - Trauma Therapy for Teens and Young Adults

Therapy Parent/Guardian Referral

Parent/Guardian Details

First name

Last name

Phone

Client Details

First name

Last name

Age

Why are you seeking therapy for your young person and how can we help?

Has the young person ever received mental health support from any of the following services? (GP, Counsellor or Therapist, CAMHS, Community Mental Health, Community Addictions, Crisis Team, Psychiatrist, Psychologist, Other - please describe.

Has the young person any formal diagnosis (i.e. OCD, ASD, ADHD etc) or any form of disability?

Any current safety concerns (self-harm/suicidal thoughts)

Preferred Session Format: face-to-face in Ballymena or Online via Zoom?

On which days and at what time of day is the young person regularly available for sessions?

I have reviewed the suggested donations and can pay:

£60/Session (parent/guardian or client is full time employed)

£35/Session (parent/guardian or client is part time employed or on benefits)

Exceptional Circumstances (see below)

If you're experiencing exceptional circumstances, we may be able to offer a further reduced rate. If this applies to you, please share a little about your situation so we can consider your request.

Subsidised rates are made possible by Progeny fundraising and donations.

I wish to submit this referral and consent to my personal data being stored and processed. I also consent to being contacted by phone or email regarding my referral.

Therapy isn't a 'crisis' service. If the client is in need of urgent mental health care, please reach out to your GP, Crisis Team or Casualty Department.

PROFESSIONAL EXCELLENCE CHRISTIAN HEART

Therapy Parent/Guardian Referral

PROFESSIONAL EXCELLENCE
CHRISTIAN HEART