Counselling and art therapy

This referral form is for any Primary 6 or 7 child who requires counselling or art therapy support and attends primary school in Fife or is home educated in Fife. Those who are home educated should have this referral completed by their parent/carer or other adult who supports them.

Requirements

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. You can download the self-harm and suicide guidance offered by Mind Matters.

Please read the options carefully and select only one from the options below. This will indicate what DAPL work stream the young person will be seen under.

You can request a preference for art therapy however this will depend on the availability of resources. Art therapy has not been commissioned as a specific option. All of the CYP&F counsellors are trained to work creatively with children and can provide a range of creative approaches to counselling.

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

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 to include your official and valid email address.

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 emotionally distressed

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

Referrer’s details

Please confirm your name and role.

Name of referrer*

Please give your full name.

Role of referrer*

Your connection to the young person.

Parent

Head Teacher

Social Worker

Other (Please give details)

Space availability

Please confirm that space and resource are available.

As the referrer you have a responsibility to ensure that there is an appropriate and available space for the counselling/art therapy work to be undertaken within the school. We also need you to ensure that all of the school staff are briefed on what is required to be able to provide counselling in the school.

Pupil support

It is essential that young people are offered appropriate support.

Neurodivergence*

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

Yes

Unknown

Young person’s details

Please ensure that you provide all of the requested information.

Overview

Please give a description of the child and the issues presented.

Details

Please provide all the details below for efficient lines of communication.

First name*

Second name*

Date of birth*

Address*

Postcode*

School*

Primary year*

Class teacher*

Teacher’s email*

Parent or carer*

Please give a description of the child and the issues.

First name*

Second name*

Relationship to the child*

Phone*

Email*

Parent or carer aware of referral?

Yes

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.

Guardianship*

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

A looked after child

On the child protection register

Subject to an order from the Children Hearing Service

None of the above

Other (Please give details)

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?

Additional information

Please do not copy and paste reports or assessments in this space.

Background

What is the background to this referral?

Consent

To proceed with this referral, the parent or carer must provide consent separately.

Please ensure that the parent, carer, or you, where consent from the parent or carer can not be acquired, has provided consent for the child to access our service. Without this consent we will not be able to begin working with them and their referral will be deleted after three weeks.

Consent form sent to parent or carer*

This is required to proceed with this referral.

Yes

Not yet

Please send the following consent form link to the parent or carer.

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

Thank you! Your submission has been received!

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