This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Integrative Arts Therapy for Children and Young People by Fee's Space Arts Child Counselling Who is this referral for? I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "3 -18 (+) with mental health needs, based in Horley, Surrey" Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode Ethnicity SelectEnglish, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White backgroundWhite and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic backgroundIndian Pakistani Bangladeshi Chinese Any other Asian backgroundAfrican Caribbean Any other Black, African or Caribbean backgroundArab Any other ethnic groupPrefer not to say Gender SelectFemale Male Transgender female Transgender male Non-binary Intersex Not specified Not known Other Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. PERSON MAKING ENQUIRY – WHAT IS YOUR RELATIONSHIP TO CHILD / YP? (if not parent then please highlight who has parental responsibility & whether they are aware of the enquiry): CHILD / YP’s SCHOOL & CLASS: REASON FOR CONTACTING FEE’S SPACE: WHAT KIND OR SUPPORT / OUTCOME ARE YOU HOPING FOR?: ANY ADDITIONAL NEEDS OR CIRCUMSTANCES (such as SEND, safeguarding issues, involvement / support with other agencies, previous counselling / therapy): ANY OTHER INFORMATION YOU THINK WOULD BE USEFUL TO KNOW? (such as previous therapy experience / waiting list for alternative support) WHERE DID YOU HEAR ABOUT FEE’S SPACE? Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
