Counselling Referral Form

The Ark, Unit 1, Marsh House, 500 Montagu Road, Edmonton, London, N9 0UR.

Tel: 020 8373 2718 (24hr answerphone)


Counselling Referral Form

To the Referrer, please be aware of the following:

1. Counselling provided by DAZU is free only to Young Carers who are on DAZU’s Young Carers’ Register. If you are referring someone who is not a Young Carer registered with DAZU, there may be a charge for the Counselling Service.

2. Our Counsellors are available during the day (Monday-Friday, 10am-5pm) and clients will be expected to attend counselling sessions at The Ark in Edmonton unless otherwise arranged. Therefore, referrer and/or parent/carer must inform the client’s school in order that the client is permitted to leave school (during school hours) to attend counselling sessions at the Ark.

3. It will be the responsibility of the parent/carer to ensure that the client attends all sessions once counselling begins. Clients and/or their parents/carers must give 24 hours’ notice to cancel.

Please complete all parts of this form.


Name of Client:  
Date of Birth:   Age:  
Ethnicity:   Gender:  
Name of Parent/Carer:  
Address & Postcode:  
Home Tel No:   Mobile No:  
GP’s Name, Address & Tel No:  
Please note any known medications:  
School Name, Address,  Tel No:  
Name of Head Teacher or Deputy :  
Name of Referrer:  
Name of Organization & Position Held:  
Address,Tel No & Email:  
Is the Client registered with DAZU’s Young Carers’ Project: Yes No
Has Client been referred to another organization? Yes No
If yes, please state organization name and if currently receiving counselling:
Parents/Carers signature date  




Reason for Referral / Client History:


Please return this form for the attention of Liz Newbury-Smith or Vivien Rodgers by post to: DAZU, The Ark, Unit 1, Marsh House, 500 Montagu Road, Edmonton, London N9 0UR, or by email to: