Guided parent-led CBT for child anxiety referral form

Our Guided parent-led CBT for child anxiety support service is available for both Anxiety UK family members and non-members.

Below is the referral form you will need to fill in to apply for the support service. As the form is quite lengthy, please make sure you have to hand:

  • Your GP Information

Please also be aware that before a therapist is allocated to you, you will need to pay for an initial number of sessions in advance. Once you have submitted your referral form, our team will review the information provided and contact you by email to confirm these payments. It is important that you have read our terms and conditions and FAQs before applying for the service to avoid any delay or confusion in processing your application.

 

If you are having difficulty filling in this form and need assistance – please call our office on 0161 226 7727

Guided parent-delivered referral form

  • Please enter a number from 5 to 17.
  • Location 1Location 2Location 3 
    Please note if we do not have a therapist trained in delivering this support in your area we will offer phone or web cam support.
    Please note this may impact the availability of therapist that match your preferred location and we may need to consider phone or web cam support to accommodate your preferences.
  • Your details

  • Please note: we need details (name and number) for an emergency contact so we and your therapist know who to call in the event they need to at any time.
  • Your GP details

    Important: Neither your therapist nor Anxiety UK will usually need to contact your GP. However; as your welfare is of paramount importance, if issues of safety arise (for example, if either Anxiety UK or your therapist believes that you are a risk to yourself or to others) he or she may need to contact your GP before commencing treatment, or as appropriate during treatment.

    Your therapist will always discuss this with you before making contact with your GP. Therefore, it is essential we have your GP contact details as, without these, we cannot process your application.
  • Please note, if you are under 16 years of age we will require a letter from your GP giving their permission for us to provide access to treatment, as well as confirmation from your parent/guardian of their consent for you to access this service.
  • Providing an email contact for your GP is not essential, but may speed up the process should we need to contact them prior to you starting therapy.
  • Your child's health

  • Including contact name and number of the team including email and postal address, plus the dates during which the service was accessed
  • Including medication prescribed and dosage.
  • 1 = fleeting thoughts of not wanting to be here; 10 = I have a plan and the will to carry out my thoughts.
  • Data Security

    If you have requested that Anxiety UK correspond with you by e-mail, which will require e-mailing your personal data outside of our own IT network. We are required to inform you there is the risk of data loss when e-mailing outside our IT network, therefore we require written confirmation (this can be an e-mail response sent to membership@anxietyuk.org.uk) that you accept this risk.
    We are happy to accept encrypted emails and documents. You can then call to provide the password over the phone. If you would like details on how to encrypt this document please contact services@anxietyuk.org.uk and the details will be passed over to you.

    Terms and conditions are available here or via the above email address.