Staff Consultation – self referral form 2024/25

The Schools and Colleges Early Support Service will be closed from Friday 20th December to Monday 6th January. Please be aware that no contact will be made from the service during your School/College's winter break.

The Staff Consultation is provided by Anna Freud. It is an individual 45-minute appointment with an optional follow up appointment via phone or video call with a trained practitioner. This can be about your own wellbeing or the wellbeing of a young person you are supporting including difficulties such as mild to moderate anxiety, stress and/or low mood.

We can only accept requests for support from people who are a staff member at one of SCESS’s partner schools or colleges.

Please note, completion of this form does not guarantee that we will be able to offer you a consultation.

One of our team will contact you shortly with more detail.

We hold all information confidentially, including information relating to equity & diversity, such as ethnicity & gender. As part of our service evaluation, we may use some information to monitor and identify where we need to focus efforts to ensure we are reaching a representative audience. For information on how we will use your data please refer to our privacy notice:

h ttps://www.annafreud.org/your-privacy/

1. First name

2. Last name

3. Preferred first name

Please complete even if it is the same as your first name.

4. What is your date of birth?

5. What is your sex?

MaleFemalePrefer not to sayOther

6. What best describes your gender identity?

7. Current concerns

Please provide the reason for the consultation and nature of the concerns.

8. Email address

9. Mobile number

10. Home address

Please give full postal address of where you live now. Do not include postcode.

11. Postcode

12. Next of kin name and contact number

13. Name of school or college

Please give the full name of your school/college. Not giving the full name will slow down the processing of your referral. If your school/college is part of an academy trust, please give the name of your specific school/college and not the name of the trust.

14. Call type preference

Phone callVideoWe offer video calls or telephone calls. Please state your preference, but we recommend a video call wherever possible.

15. What times are you available for a consultation?

Please note, our opening hours are 09.00 and 18.00 Monday - Thursday and Friday 09.00 - 12.00. If we are able to proceed with supporting you we will attempt to book an appointment with you to avoid these times but we can not guarantee this.

16. What times are you not available for a consultation?

Please note our opening hours are 09.00 and 18.00 Monday - Thursday and Friday 09.00 - 12.00. We are unable to book consultation times outside these hours.

17. Do you have any special requirements or preferences which may help to make this Service more accessible to you? (If none, please write "none").

Examples of accessibility requirements include visual or hearing difficulties. Please give details of what adjustments might be needed.

Contact Information