Enquiry Wizard

Complete the following referral form to submit a request for counselling at Young Devon .

Client

Personal Information

Enter the client's forename.
Enter the client's surname.
Enter a contact number for appointments.
Enter an email address for appointments.

 

Please enter the client's date of birth (format: dd/MM/yyyy)
If client is under 13, please enter a parent/guardian's name and contact number.
Please select the clients gender.

Address Information

Enter a street and house number.
Optionally enter a town.
Enter the first part of the postcode (e.g MK6)
Enter the second part of the postcode (e.g 5LP)

Additional Information

Select one or more of the issues you are experiencing.
Please give a brief summary of why support is required (including any relevant medical/family history).
Please give a brief summary of when you are available.

Consents

“Counselling is an activity entered into of your own free will, in order to explore and understand issues which may be causing difficulty, pain and/or confusion” (Youth Access 2004)

To get the most from your counselling, we will agree and establish expectations.
Together we will make arrangements for how we plan our sessions

Confidentiality

What you tell us is confidential. We will not tell anyone outside of Young Devon what you have said to us, or what we have said to you – except – when you have told us it is OK, or when you or someone else is at risk of serious harm.

If you are accessing Online Counselling, your counsellor will encourage you to think about your privacy at home while your session is happening.
No recording of online sessions will be made without the consent of both parties.

Safety

If your session ends abruptly and your counsellor is worried for your safety, we will try to contact you to make sure you are safe. If we cannot reach you, we will attempt to contact your parent/ carer/ trusted person.
We will agree a wellbeing plan together at our first meeting.

 

YOUNG DEVON INFORMATION NOTICE

Young Devon holds information about you to help us work with you. Some of this is given to us by organisations who have suggested you get help from us. In this case we have a legitimate reason to hold that information to help keep you safe.
Young Devon may need to ask permission from you before we collect, keep and use certain information about you. If you are under 13 we may need your parents/guardians signed permission. These notes will help you make the decision about whether or not you give us consent. You can withdraw consent at any time.
You will always have the right to see what information we hold about you and to make sure it’s correct. If you are ever not sure about why we keep information please ask your support worker, any member of the team or get in touch at info@youngdevon.org or 01752 691511.
If you have any questions about this notice, please ask any team member and we’ll be happy to help.

Why does Young Devon need to keep information about you? So that we can:

  • Carry out risk assessments and make plans to manage any risk
  • Assist you in an emergency
  • Review if you are getting a useful service from Young Devon
  • Offer you other Young Devon services if we think it will help you
  • To ensure that all our services are open to all and are fair and equal
  • Use anonymous information to:
    • Show the people who we work for and who fund our work what we do
    • Provide numbers and facts to support us to do more work with young people.
    • Support campaigns to provide better services to young people

What sort of information might Young Devon keep about you?

  • Names and contact details of you and your family/carers/guardians.
  • Your support plans which we use to help you progress and achieve your goals, including the ‘outcome star’.
  • Notes taken in your meetings/sessions/counselling – this may include your concerns/anxiety /areas you want more support with/and the positive things you are involved in.
  • Details of your health and wellbeing/additional support needs or disability.
  • We can upload information you would like us to keep for you on our database.
  • Personal sensitive information for monitoring purposes.
  • Letters, emails and text messages that you send us or we send you.
  • Letters, emails that we receive from other organisations working with you.
  • Legal information that we may use to support you.
  • Information about you to help us work better with you and other organisations

How do we keep this information about you safe?
We minimise the amount of paperwork with your personal information on and it is kept securely locked. Electronic files are kept in safe storage systems and can only be accessed by your Young Devon workers who have authorisation.
If you think your safety is at risk by others knowing your address/contact details you must tell your worker. If there are people/agencies you would prefer us not to share information with please tell your worker.
It is important that the information we keep is accurate, and we only record what is needed and that it is only used in ways that you agree to (unless we have a legal duty to share it). You can request to see your information we keep. Please speak to a team member so this can be arranged.
We will only share this information with people if we need to in assisting any claims, areas of support you need, and it will support your safety. We will do this with your permission.
If you are at risk we have a legal duty to share information with other agencies such as the Local Authority Safeguarding Team and/or the Police, when it’s possible we will always tell you what we are going to do. Examples might be;

  1. We have serious concerns about your safety.
  2. We have information that makes us think you are at risk of harm.
  3. You need urgent medical treatment.
  4. You may be involved/associated with a serious crime.

Young Devon will ensure that information is managed in line with our Data Protection Policy, the Data Protection Act 2017 and the General Data Protection Regulations 2018.

 


NHS Permission

Our data is sent anonymously to the NHS so that they can track mental health in our area. The data set is used to inform service improvements and monitor service performance,
clinical interventions, patient experience and treatment outcomes. Are you happy for your data to be sent to the NHS?

Access permission

I consent that you can share details with my GP and other 3ʳᵈ parties who are involved in the contract entered into by you and us

Communication Permission

I consent that I'd like to hear from you via email

I consent that I'd like to receive SMS texts from you

I consent that I'd like to receive letters from you

I consent that I'd like to receive phone calls from you and you can leave voice messages

Leave unchecked and we will NOT contact you via this method, a minimum of ONE consent must be given.