Counselling Form

1. Employee details

   1. Please complete this online form if you want to refer yourself or an employee for Counselling.
      
      Before proceeding please ensure that you have read and accept our privacy policy, terms and conditions.
      
      We collect, hold, and manage all information in accordance with our data protection regulations.
      
      All details recorded in this section relate to the personal details of the employee being referred.
   2. First Name*
   3. Surname*
   4. Directorate/Employer Please Select Adult Social Care Business Development Team Commissioning Therapy Services Derwent Hill and Retained Education Learning and Skills and Library Services SSCP Infrastructure and Transportation Port of Sunderland Regulatory Services Strategic Development Schools/Academies Assurance and Procurement Coordination and Technical Revenues and Benefits Health and Wellbeing Housing and Communities Integrated Commissioning Public Health ICT Law and Governance People Management Smart City Strategic Customer Enabling Services Transformation Project Team Area Arrangements City Data Corporate Strategy Team Internal Communications Learning and skills People Communications Place Communications Social Cohesion - strategic Finance Start Service Supported Living Chief Executive Services Children's Social Care Early Help Education TfC Finance Service TfC Other
   5. External Customer Please Select Age UK Sunderland Liebherr Sunderland Carers Centre Tyne and Wear Fire & Rescue Service CBC Health Federation Brick Technical Westmoorland and Furness Council RE:GEN Tyne Coast Academy Trust BCCET Washington Mind Oculus HR Ltd Oak Learning Trust Fulwell Medical Centre Sunderland Bid Durham County Council
   6. School/Academy Please Select Academy 360 Adderlane Academy Albany Village Primary School Ash Trees Academy Barbara Priestman Academy Barmston Village Primary School Barnes Infant Academy Barnes Junior School Barnwell Academy Beacon of Light School Benedict Biscop Church of England Academy Bernard Gilpin Primary School Bexhill Primary Academy Biddick Academy Biddick Primary School and Nursery Blackfell Primary School Broadway Junior School Burnside Academy Inspires Castle View Enterprise Academy Castletown Primary School Columbia Grange School Croftway Academy Dame Dorothy Primary School Diamond Hall Infant Academy Diamond Hall Junior Academy Dubmire Primary Academy Dunn Street Primary School Early Days Nursery Ryhope Infant Easington Lane Primary School East Herrington Primary Academy East Rainton Primary School English Martyrs RC Voluntary Aided Primary School Eppleton Academy Primary School Esh Winning Farringdon Academy Farringdon Community Academy Fatfield Academy Inspires Fellgate Primary School Fulwell Infant Academy Fulwell Junior School George Washington Primary School Gillas Lane Primary Academy Grange Park Primary School Grangetown Primary School Grindon Infant School Haltwhistle First Academy Haltwhistle Middle Academy Hasting Hill Academy Hetton Lyons Nursery School Hetton Lyons Primary Academy Hetton Primary School Hetton Secondary School Highfield Academy Hill View Infant Academy Hill View Junior Academy Holley Park Academy Hope Wood Academy Houghton Community Nursery School Hudson Road Primary School Hylton Castle Primary School Hylton Red House Nursery School Ian Ramsey C of E Academy John F Kennedy Primary School KS1 Pupil Referral Unit Lambton Primary School Malvin's Close Academy Marine Park Primary School Marlborough Primary School Mill Hill Nursery School Mill Hill Primary School Monkwearmouth Academy Monkton Academy Morpeth Road Academy New Beginnings Nursery New Penshaw Academy New Seaham Academy New Silksworth Infant Academy New Silksworth Junior Academy Newbottle Primary Academy North View School Northern Saints Church of England Voluntary Aided Primary School Our Lady of Lourdes RC VA Primary School Our Lady Queen Of Peace RC Voluntary Aided Primary School Our Lady Star of the Sea Roman Catholic Primary School Ouston Primary School Oxclose Community Academy Oxclose Community Nursery School Oxclose Primary Academy Pennywell Early Years Centre Plains Farm Academy Portland Academy Prudhoe West Red House Academy Redby Primary Academy Richard Avenue Primary School Rickleton Primary School Riverside Primary Academy Ryhope Infant School Academy Ryhope Junior School Sandhill View Academy Seaburn Dene Primary School Shaftoe Trust Shiney Row Primary School Southmoor Academy Southwick Community Primary School Springwell Village Primary School St Aidan's Catholic Academy St Aloysius Catholic Infant and Junior School St Anne's RC Voluntary Aided Primary School St Anthony's Girls' Catholic Academy St Bede's Catholic School and Byron Sixth Form College St Bede's Catholic Primary School St Bede's RC Primary School - Jarrow St Benet's RC Voluntary Aided Primary School St Cuthbert's RC Voluntary Aided Primary School - New Seaham St Cuthbert's Roman Catholic Voluntary Aided Primary School - Grindon Lane St Godric's RC VA Primary School - Thornley St Gregory's Catholic Primary School St James Catholic Primary School St John Bosco Voluntary Aided School St John Bosco Catholic Primary School St Joseph's Catholic Academy - Hebburn St Joseph's Catholic Infant School - Blackhall St Joseph's Catholic Junior School - Jarrow St Joseph's RC VA Primary School - Sunderland St Joseph's Washington RC School St Leonard's RC Voluntary Aided Primary School St Mary Magdelene Roman Catholic Voluntary Aided Primary School St Mary's RC VA Primary School St Matthew’s Catholic Primary School St Michael's RC Voluntary Aided Primary School St Oswald's RC VA Primary School St Patrick's RC Voluntary Aided Primary School St Paul's CE Primary School St Peter and Paul RC Primary School St Robert of Newminster Catholic School and Sixth Form College St Wilfrid's RC College Sunningdale School The Link School - Springwell Dene/Pallion The Venerable Bede Church of England Academy The Virtual School - Portland Road Thorney Close Primary School Thornhill Academy Town End Academy Usworth Colliery Nursery School Usworth Colliery Primary School Valley Road Academy Washington Academy Washington Day Nursery Welbeck (Wise Academies) Wessington Primary School Whitburn Village Primary School Willow Wood Primary School
   7. Date of Birth
   8. Job Title
   9. Contact Telephone Number
   10. Address line 1
   11. Address line 2
   12. Town or City
   13. Post Code
   14. Email Address
   15. Please only provide an email address that is confidential to the employee and ensure that they are comfortable that this will be used for the purposes of a referral to the counselling service
   16. Email Address of Budget Holder
   17. Please provide an email address of a member of staff within your organisation who manages your budget. Payment must be authorised before the service can be delivered.
2. Next