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Counselling Referral Form – Pink

This form allows schools or families to refer a pupil or child/young adult for support from Vista Support Services. Referrals will be reviewed once consent from a parent or guardian has been received

Please follow the steps below to ensure the referral is processed correctly:

  1. Complete the form, ensuring all required fields are filled in and any additional relevant information is included.

  2. Submit the form.

  3. An email will automatically be sent to the parent or guardian with a secure link.

  4. The parent or guardian will review the information entered (read-only) and complete the consent section.

  5. Once the parent has signed and submitted, the completed referral will be securely received by Vista Support Services.

Childs Details

DD slash MM slash YYYY
Gender(Required)
Address(Required)

Parent/ Carers Details 1:

Parental Responsibility?(Required)
Gender(Required)
DD slash MM slash YYYY
Is an interpreter required?
Address (if different from Child)

Parent/ Carers Details 2:

Parental Responsibility?
Gender
DD slash MM slash YYYY
Is an interpreter required?
Address (if different from Child)

Significant Others/Siblings

Details
Name
Address
DOB
Relationship to child
Gender
 

School Details

Other services involved with the child/family:
Name of Organisation
Contact Name
Contact Number/Email
Other services involved with the child/family:
 
Please outline your concerns:

The Counselling service can only start once the:

  • Vista Counsellor Agreement has been signed by a parent/ guardian
  • Vista Counsellor – GDPR Policy has been signed by a parent/guardian

For help and assistance filling out this form please call 01727 519128

Vista Counsellor – GDPR Policy

The General Data Protection Regulation (GDPR) is primarily concerned with ensuring that your personal information is protected. This document explains how Vista do that. Please read and sign the last page to indicate that you agree with Vista’s procedures.

Vista St Albans CIC ICO number: ZA354653

Personal information Vista will collect:

  • Name
  • Gender (or preferred identity)
  • Age
  • Date of Birth
  • Child’s relationships including parents, carers, siblings and significant others
  • School information
  • School year group
  • Address
  • Telephone numbers of parents/carer (plus permission to send SMS and leave voice message)
  • Email address of parent/carer
  • Medical conditions related to counselling
  • Presenting issues
  • Underlying learning difficulties and diagnoses
  • Ethnicity
  • Religion
  • Language
  • Session summary
  • Other services involved with child/family

How Vista store your personal data

Storage methods

  • Paper written notes are stored in locked cabinets.
  • Smartphone: Allows Vista to contact school/parents/carers.
  • CRM system: Used by authorised staff only, password-protected.
  • Email/SMS/WhatsApp: Contact details and correspondence stored as per usage.

Email – Privacy, Security and Confidentiality

  • Vista uses Microsoft email which is GDPR compliant and encrypted.
  • Emails may be logged by Internet Service Providers (ISPs).
  • Use email only for non-confidential communications.

Documents which may or may not be held on Paper

  • Contact sheet
  • Contract agreement
  • Brief session notes
  • GDPR agreement
  • Permission to disclose form
  • Safeguarding form
  • Creative consent form
  • Referral form

Documents which may or may not be held electronically

  • Contact sheet
  • Contract agreement
  • Brief session notes
  • GDPR agreement
  • Permission to disclose form
  • Safeguarding form
  • Creative consent form
  • Referral form
  • Contact name and telephone number
  • Email/SMS/WhatsApp

How Vista process and share information

  • Supervision with qualified therapists (supervisors don’t know the child personally).
  • Cloud printing via GDPR compliant servers.
  • Information may be shared with Vista Management if required.

Erasing Information

Vista retains paper and electronic records for up to seven years post-counselling. After this, written information is shredded and electronic records are deleted.

Your rights

  • To be informed of what information Vista hold
  • To rectify any inaccurate or incomplete personal information
  • To withdraw consent for Vista to use personal information

I agree to Vista holding the above data about the child/young person.

Clear Signature
DD slash MM slash YYYY

Vista Counsellor Agreement

Counselling contract for Student Named on this form receiving therapy within a school setting with a Vista Counsellor.

A Vista Counsellor will:

  • Offer a safe place within the school premises for the child/young person to share their experiences and difficulties.
  • Support the child/young person and help them work through their experiences but will not give advice or tell them what to do.
  • Keep all information (called data) safe – see GDPR policy.
  • Schedule weekly sessions within the school environment on the same day and time.

Parent/Carer understands the following:

  • Commitment to the process is extremely important. It’s vital for the young person to attend ALL sessions where possible.
  • Parent can notify the counsellor if the child is unable to make a session due to illness or unforeseen circumstances.
  • All counselling sessions are confidential. Vista Counsellors will not share information about sessions with parents/carers without the young person’s consent. However, if risk is involved, parents/carers will be notified either by the Counsellor and/or the school.
  • Full payment is required in advance if privately funded.
  • To cancel or reschedule your session, please contact your counsellor directly. This can be done via their email, mobile, or by calling 01727 519128. Failure to give 24 hours’ notice will result in your session still being charged.

I agree with the above agreement.

Clear Signature
MM slash DD slash YYYY

All Vista St Albans staff are DBS checked and attend regular safeguarding training as well as their relevant qualifications. Vista is GDPR compliant. Our ICO registration number is ZA354653

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