Referral for a Child or Young Person (under 18)

Thank you for considering making a referral to Psychological Pathways. We appreciate it can be difficult for people to find the right service when they are in need. Our service is designed to support clients with mild-moderate emotional health and wellbeing needs and where a short-term intervention can be helpful.
We appreciate that you and/or your family may be experiencing difficult challenges at this time but it is important for you to understand that we do not automatically accept all referrals we receive and we reserve the right for appropriate clinical decision making as to whether we are able to provide the correct intervention and support for you and/or your family. Please see our ‘Frequently Asked Questions (FAQs) document for more information.

Young Children

Details for person making the referral

If you are making a referral for for a child/young person (under 18) we need some information about you

Can we leave a message?
Can we send a text?
Are you the next of kin ? (if not please provide next of kin details below)
Details for the child/young person (requiring support)
DD slash MM slash YYYY
Next of Kin Details (if not already provided)
Reason for Referral

Please describe some of the concerns that have led you to seek support now, including how long these concerns have been present. Please see our (FAQs) for details on what is/is not considered an appropriate referral for our service.

Additional Information:
Services currently involved

Please list any professionals or services that the child/young person are either waiting for or are currently involved with (eg CAMHS, psychiatry, harm reduction services or other talking therapies eg counselling). Please provide brief details of the nature of these difficulties.

Services previously involved
Initial Assessment:

Initial assessment appointments are for the parent(s)/guardian(s) only. An adult only appointment allows for a more comprehensive start to assessment, also allowing a more open discussion and explanation of concerns without the child/young person being present.

We can provide initial assessments in a range of ways.

How do you wish to pay

*Please note, our practice is not registered with all UK wide PHI providers but we will advise you if this affects your referral before proceeding.


Please choose one of the options below (one of these needs to be ticked/a required field). I have the appropriate authority to make this referral because:

Please choose one of the options below. I have the appropriate authority to make this referral because:(Required)

We will not share your information with anyone outside our practice, unless we believe you, or someone else is at imminent risk of harm. In this instance we are legally bound to share information in order to keep you or others safe.

I hereby agree that the data entered in this referral form will be stored electronically and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time.

I confirm I have read and agree to the above statements regarding GDPR(Required)
Psychological Pathways does not automatically accept all referrals received and reserves the right for appropriate decision making with respect to the criteria detailed in the FAQs as to what is/is not considered to be an appropriate referral for our service.
If you have any concerns about safety (your own or others) please contact your GP, Out of Hours GP, Lifeline NI (24/7) crisis helpline, 0808 808 8000 (deaf and hard of hearing Textphone users can call Lifeline on 18001 0808 808 8000).