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Home > Make a referral > Refer To Plymouth Counselling Services

Make a secure online referral to the Plymouth Counselling Services

Step 1 of 8 – Who are you making a referral for?

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Please select the Therapy service*
- Therapy for an adult 18years plus
- Therapy for a Young Person aged 11-18 years
- Play Therapy Service for children aged 4-11 years (Professional referrals only)
Please click to confirm and acknowledge that
- Select All
- Parent/guardian’s permission is granted for the child to engage in therapy
- The parent/guardian will participate in the Assessment
- The parent/guardian will support the child’s regular attendance
- If parental support is not available, the referrer/social worker/school representative is required to support the above
Are you making this referral*
- For you
- For someone else

Hidden
Referral for someone else
If you are making the referral for someone else*
- I confirm that I have obtained written or verbal consent from the person I wish to refer which allows you to share information with First Light. The person is aware of this referral and has consented to the details contained within the referral form to be shared in accordance with the General Data Protection Regulation (GDPR), the Data Protection Act 2018 and other UK or EU data protection.
Referrer's contact details
Prefix First Last
Address
Street Address Address Line 2 City County ZIP / Postal Code Country
Landline
Mobile number
Email
Are you*
- Friend or relative
- Professional
Profession
Agency Contact details if different to above
Nature of contact with referee
All further questions in this online referral relate to the person being referred, and should be answered on their behalf where known

Hidden
Making Contact
Name*
Prefix First Last
Name you would like us to use
Pronouns
- He/him
- She/her
- They/them
Date of Birth
DD slash MM slash YYYY
Address
Address Line 1 Address Line 2 City County Post Code Country
Mobile*
Landline
Email*
Preferred contact method*
- Landline
- Mobile
- Email
- Letter
Is it safe to leave a message?*
- Landline
- Mobile
How is it safe to contact you?*
- Landline
- Mobile
- Email
- Letter
When is the best time to make contact?

: Hours

Minutes

AM/PM
Are you able to communicate in English?*
Is an interpreter required?
- Yes
For under 18’s only
Are you*
- Under 18
- Over 18
By completing this form you are giving permission for First Light to share these details with the Devon & Cornwall Sexual Assault Centre Paediatric Service*
- I agree
More infomation about this service
Name of parent/guardian if under 18 only
Prefix First Last
Relationship to child or young person if under 18 only
Contact details of parent / guardian (if different from above)
Address Line 1 Address Line 2 City County Post Code Country
Mobile
Landline
Email

About the abuse, assault or violence
To enable us to provide the person with the appropriate support we require the following information:
Type of abuse*
- Rape
- Sexual Assault by Penetration
- Childhood sexual abuse
- Child Sexual Exploitation
- Online sexual grooming
- Other
Time of incident*
- Within 24 hours
- Within 72 hours
- Within 10 days
- Within 6 months
- Over 6 months
- Over 12 months
Age at time of incident*
- Under 18
- 18 or over
- Both
About the person who committed the abuse, assault or violence
Name, if known
Prefix First Last
Are they known to you, and if so how?
- Aunt/ Uncle
- Carer
- Cousin
- Ex-Partner
- Family Member
- Father
- Foster Parent
- Friend
- Known Person/ Associate
- Mother
- Partner
- Sibling
- Son/ Daughter
- Step Child
- Step Parent
- Unknown Person/ Stranger
- Work Colleague
- Other
Number of perpetrators*
Is there a restraining order or injunction?*
- Yes
- No
At the time of the offence were you intoxicated?*
- Yes – Alcohol
- Yes – Drugs
- Yes – Both
- No
- Unknown
Was the perpetrator intoxicated at the time of the offence?*
- Yes – Alcohol
- Yes – Drugs
- Yes – Both
- No
- Unknown
Was a weapon used*
- Yes
- No
Further comments

Police investigation
Has the incident been reported to the police?*
- No
- Yes
Date reported
DD slash MM slash YYYY
Has there been an investigation?
- Within last 12 months
- Longer
Has there been a court case?
- Within last 12 months
- Longer
- No
Is there a criminal investigation ongoing?*

More About You
We will use the information you provide to help us support you more effectively. We also use equality and diversity data to help us reach everyone affected by sexual violence.
Gender*
- Male
- Female
- Other
Other
- Gender fluid
- Genderqueer
- Intersex
- Non-binary
- Questioning
- Transgender
- Prefer not to say
Gender at birth*
- Male
- Female
Ethnic origin*
Religion*
Sexual orientation*
- Asexual
- Bisexual
- Gay
- Heterosexual
- Lesbian
- Not defined
- Pansexual
- Questioning
- Prefer not to say
Relationship status*
Caring responsibilities*
Do you have a learning difficulty?*
- Yes
- No
- Prefer not to say
Please provide details
Do you have a physical disability?*
- Yes
- No
- Prefer not to say
Please provide details
Do you have any mental health issues?*
- Yes
- No
- Prefer not to say
Please provide details
Are you in contact with other professionals?*
- Yes
- No
- Prefer not to say
Are you alcohol or drug dependent?*
- Yes
- No
- Prefer not to say

Any other relevant information
Any other relevant information

Where did you hear about us
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First Light is the operating name of First Light South West Ltd
Company number: 03440794 registered in England and Wales | Charity registration number: 1090457
Registered address: The Business Centre, 2 Cattedown Road, Cattedown, Plymouth, PL4 0EG

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Make a secure online referral to the Plymouth Counselling Services

Step 1 of 8 – Who are you making a referral for?

Referral for someone else

Making Contact

For under 18’s only

About the abuse, assault or violence

Police investigation

More About You

Any other relevant information