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Request for Counselling/Psychotherapy

CONFIDENTIAL

Thank you for completing this form. Answering as fully as possible will help us ensure you are seen as quickly as possible and help us to appropriately allocate the funding we receive. We will use the information you provide here to allow us to contact you in relation to our therapeutic services only. For further information about how we treat the details you provide, please read our Privacy Notice on our website or speak to a member of staff.

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Have you directly or indirectly, been touched by NI conflict?
Have you been affected by sexual, emotional, or domestic abuse/violence?
Are you 16 or under? (for 16 and under please also read and complete the reverse side of form)
Is your referral relating to? (PLEASE TICK AS APPROPRIATE)

ARE YOU AVAILABLE FOR AN APPOINTMENT AT SHORT NOTICE

PLEASE COMPLETE THIS SECTION IF THE REFERRAL IS BEING MADE BY A HEALTH / EDUCATION PROFESSIONAL, AN AGENCY, AN ORGANISATION
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This field is for validation purposes and should be left unchanged.

FOR CHILDREN & YOUNG PEOPLE AGED 16 AND UNDER

IMPORTANT NOTES:

  • Play Therapy and Counselling for children & young people is a limited service, available to:
    •  those coping with bereavement or loss. [children 5 yrs.+ and in Primary School]
    • those experiencing trans-generational impact of the NI Troubles. [5yrs. to 16yrs.]
  • The Aisling Centre requires permission from a parent or person with parental responsibility for
    children and & young people 16 and under to engage in therapy.
  • It is our preference, where parental responsibility is shared, that both parties consent to, or at
    least know, that this request for counselling has been made on behalf of the child/young person.
PROCEDURE AFTER A REFERRAL IS RECEIVED FOR A CHILD/YOUNG PERSON

When a therapy place becomes available, a meeting will be arranged between the child / young person, the therapist and the person/s holding parental responsibility. The following will be agreed during the initial meeting:

  • Confidentiality boundaries
  • Participants to the counselling sessions
  • Periodic reviews with the child/young person
Is your referral relating to? (please tick as appropriate)
Is the Child/Young Person aware that this referral has been made on their behalf?

Accepted file types: jpg, gif, png, pdf, Max. file size: 64 MB.
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