Counselling

This referral form is for any young person in Fife of secondary school age who may require counselling. During term time the referral should be completed by the guidance teacher or another member of Fife Education Service. During the summer break we will accept referrals from parents, carers and other professionals.

Requirements

Please fill in this form with the young person that you are going to refer. We appreciate that sometimes you may not be able to fill in the whole form while the young person is with you but there are some essential things that both the young person, the referrer and potentially parents and carers need to know. Please note that Parental or Guardian consent is not legally required for secondary aged young people.

Please remember this referral is for counselling. It is not an emergency or crisis service. If the young person is expressing a wish to die and says that they have a plan of what to do, you must ensure that they are seen urgently by CAMHS or attend the local Emergency Department.

Apply Below

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The process we follow

You will receive an automated receipt for this referral
We will only contact you if the referral is rejected
Young people will be added to the waiting list for their school
Contact the service coordinator for progress updates
We will contact the young person directly via the mobile or email
The young person needs to take responsibility for attending the counselling sessions and communicating with their counsellor
If they don't attend and don't contact the counsellor their case will be closed
If the young person's mobile number changes, they leave school, move to another school or no longer want to access counselling please let us know

Contact details

We need an email address to reply to you directly.

Please note that any fields or sections marked with a green asterisk * are required.

Email*

Please ensure that your email address is official and valid.

Wellbeing*

Please select one option from the two sections below.

This will indicate what DAPL work stream the young person will be seen under.

Substance abuse

Affected by own or another’s substance use.

The young person is using alcohol and or drugs

The young person affected by another’s alcohol and or drug use

Emotional wellbeing

Education staff only or carers of a home educated child.

The person is presenting emotionally distressed

In addition to the intensive stage outlined within the Our Minds Matter framework?

Pupil equity fund

Does the young person meet the agreed criteria for any the following DAPL commissioned schools?

Commissioned schools

This informs us of available funding.

Dunfermline High School

Glenrothes High School

Levenmouth Academy

Queen Anne High School

School support

It is essential that young people are offered appropriate support proportionate to their needs.

In accordance with the OMM continuum of support please consider all universal, in school supports and other wellbeing options prior to making a counselling referral. If a young person hasn't been offered, considered or accessed these supports it is likely that the counselling referral will be rejected.

Wellbeing in Fife

Has the young person been offered an enquiry to the Wellbeing in Fife Service, including Barnardos?

Yes

Not yet

Consultation or signposting

Has there been a discussion of the young person’s needs?

Prior to submitting a referral for counselling has there been a discussion of the young person’s needs with any of our partners or other professionals and did they suggest a referral? Did the Parent or Carer request the referral be made?

Intervention*

If nobody is listed, DAPL will defer the sole decision to the young persons guidance teacher.

Nobody

Guidance teacher

Parent or Carer

DAPL

Assessment

If the young person has been referred to CAMHS, please indicate how they have advised a referral to the School Counselling Service?

Therapeutic letter

Consultation

Primary assessment of need appointment (PANA)

Please provide the brief note that the CAMHS Early Intervention Service worker has provided to support this referral. (Consultation or PANA only).

Who suggested a referral to DAPL?

Informing us of the chain of events leading up to this referral can help us to coordinate with other people and organisations.

Primary contact

Other

Young person’s details

Please ensure that you provide all of the requested information.

We use this to make contact the young person and to generate their client profile. It is also essential that we have accurate and up to date information to be able to contact the next of kin in the event of an emergency.

Personal information

Please note that this information will be kept safe and secure in accordance with our privacy policy.

First name*

Second name*

Address*

Postcode*

Town*

School*

Year group*

Date of birth*

Email*

Mobile*

Consent

The young person being referred needs to be aware and be in agreement with the referral being made.

Parents and carers do not need to give permission or be made aware of a referral being made to the School Counselling Service. However it can be useful if they are willing to help the young person to access counselling and support the process.

Young person consent

Please confirm all three points below and communicate that a failure to attend and talk with counsellors will close their case.

The young person has given consent for this referral to be made*

They have confirmed they wish to access counselling*

They understand that they must commit to attending the sessions and communicating with the counsellor*

Parent and carer consent

Does the young person want their parents or carers informed?

Yes

Not at the moment

Emergency contact

Does the young person want their next of kin, parents or carers informed?

Emergency contact*

Relationship to young person

Emergency contact number*

Emergency contact email*

Appointments

All appointments will be offered in school or via online or telephone.

Appointments may occasionally be offered outwith school if appropriate and if resources allow. The School Counselling Service works throughout the Easter, Summer and October holidays.

Outside appointments

Do they require appointments outwith the school?

Yes

If yes, please give details below:

School holidays

Are they willing to attend appointments during school holidays?

Yes

Unsure at this point

Referrers details

Please provide the information requested below as fully as possible to ensure clear lines of communication.

Personal details

Please note that this information will be kept safe and secure in accordance with our privacy policy.

Name of referrer*

Position of referrer*

Email*

Date of submission*

Name of guidance teacher

Guidance teacher’s email

Name of Health Centre or GP surgery*

Name of GP

Name of social worker (If allocated)

Social workers email

Young person support

Is the young person is currently being supported by any of the following services?

Neurodiversity

Is the young person currently on the pathway for an ASD or ADHD assessment?

Yes

Unknown

Other

Guardianship

Are there any circumstances around the young person's guardianship?

A looked after young person

On the child protection register

Subject to an order from the Children Hearing Service

None of the above

Other

Counselling

Is the young person already engaged with a counsellor?

We will not be able to accept a referral if the young person is already engaged with a counsellor or is accessing ongoing psychological support from another agency.

Counselling services

Is the young person:

Currently working with a counsellor

Currently supported by CAHMS

Currently being supported by the OMM PSO

Presentation summary

Is the young person currently presenting with any of the following issues?

The initial presenting issue may however hide wider issues. Please ask the young person directly if any of the co-occurring issues are a factor when placing a referral. In the second section please select all that are relevant.

Self-harm and suicide

Please remember this referral is for counselling, it is not an emergency or crisis service.

If the young person is expressing a wish to die and says that they have a plan of what to do, you must ensure that they are seen urgently by CAMHS or attend the local Emergency Department.

Currently self harming?

Is the young person self harming?

Yes

History of self-harm?

Does the young person have a history of self-harm?

Yes

Steps taken

If the young person is self harming, what action have you taken to ensure their safety?

Suicidal thoughts?

Is the young person currnetly considering suicice?

Yes

History of suicidal thoughts?

Does the young person have a history of suicidal behaviour?

Yes

Steps taken

If the young person is talking about suicide or undertaking suicidal behaviours, what action have you taken to ensure their safety?

Areas of change

Please note key areas of behaviour and or presentation identified for change.

Please do not copy and paste CAMHS, PMHT, SNS or other NHS notes here, provide your own observations.

Main aspects of presentation or behavior change

Please link your comments to the primary area of concern outlined above in the presentation summary.

Communication needs

Please note communication needs, access issues or risk factors etc.

Special requests

We aim to provide young people with the best service that we can.

We are asking for a preference however we need to provide a service within a reasonable timeframe. Even if one preference is noted we may offer an alternative to ensure that the young person get support. Please make sure that the young person knows that there is no guarantee that their preference will be available.

Therapy preference

Please note communication needs, access issues or risk factors etc.

Counselling or art therapy (no preference)

Counselling talking therapy only

Art therapy only

Specific DAPL worker

Before submitting your referral, please double-check that all required * fields are complete.

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If you need help urgently, here's a list of contacts who can help.

Counselling

Requirements

Contact details

Wellbeing*

Pupil equity fund

School support

Consultation or signposting

Young person’s details

Consent

Appointments

Referrers details

Young person support

Counselling

Presentation summary

Self-harm and suicide

Areas of change

Special requests

Leven

Kirkcaldy