Counselling referral form

If you would like you child to receive counselling support please complete the form, below, and then click on the ‘submit’ button.

Alternatively feel free to discuss your concerns with your child’s teacher. Following this discussion, and with your agreement, he/she can make the referral on your behalf.

a painted wall that says 'welcome to inscape house school'

Counselling referral form

If you would like you child to receive counselling support please complete the form, below, and then click on the ‘submit’ button. Alternatively feel free to discuss your concerns with your child’s teacher. Following this discussion, and with your agreement, he/she can make the referral on your behalf.

Company

This field is for validation purposes and should be left unchanged.

Date of referral(Required)

Full name of child/young person(Required)

First Last

Date of birth of child/young person(Required)

Please provide the reason for your referral and any useful background information(Required)

Name of referrer (Your name)(Required)

First Last

Your email address(Required)

Your phone/mobile number

Preferred method of contact (mobile or email)(Required)

Referrer’s relationship to the child/young person(Required)

I agree to be contacted by the Inscape Counselling Service to discuss the support requirements for my child/young person(Required)

Yes

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Inscape House School

About Inscape House School

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Counselling referral form

Counselling referral form

At Inscape House School, we break down barriers to learning for autistic children.

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