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Referral Form

1. Who Is Completing This Form?
I am a student referring myself
I am parent/guardian referring my child
I am a teacher/school contact referring a pupil
4. Date of Birth:
5. Gender:
Male
Female
Other
8. Year Group:

Contact Details:

Referrer Details:

(only complete this section if you are not a pupil referring yourself)

18. Has This Young Person Consented This Service?

Important Information to Consent:

By clicking 'I Agree' below, you are agreeing to the following:


1. Confidentiality

I understand that counselling is confidential, with certain exceptions:


- If there is a risk of you harming yourself or being harmed

- If there is a risk of harm to another person

- If there is a risk of a serious crime being committed


I am aware that the counsellor will only share this information with those who absolutely need to know.


2. Releasing Information

If a parent, teacher, or another person (such as a GP or social services) inquires about my counselling, my counsellor will not share any information unless I give my consent.


3. Records

I consent to Make A Melody processing my data. This includes securely storing my personal information, such as my name and date of birth, in a database. Make A Melody will use this data to contact me and maintain records of my counselling sessions. My data will be kept confidential and will be destroyed when it is no longer needed. I have the right to access my records at any time and request corrections if there are any errors. I also consent to my school sharing relevant GDPR details with Make A Melody.


4. Review

We will schedule six counselling sessions. Once these sessions are completed, we will review my progress and decide together on the next steps. I understand that attending counselling is my choice, and I can choose to stop at any time.

Please use the below links to read our full terms and conditions and privacy notice:

Terms and Conditions

Privacy Notice

Single choice
I Agree
I Do Not Agree (your referral will not be completed if you choose this option)

After receiving your details, we will add you to our waiting list and contact you to arrange an appointment.

 

Please be aware that this is not an emergency service. If your circumstances change and you need immediate support, consider reaching out to one of the following:

 

- Your school’s Head of Pastoral Care

- Your parent or guardian

- Your GP

- Visit us during our drop-in hours

 

You can also reach out to:

- Childline at 0800 1111

- Lifeline at 0808 808 8000

- Text ‘Shout’ to 85258 for assistance via text.

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