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Children's Counselling Referrals

Rossendale Hospice Referral Form - Child or Young Person

This form should be used for referrals for a child or young person and include guardian details. Please complete this form as completely as you can.

Service Required

Child or Young Person's Information

Next of Kin / Parent / Guardian Details

School / College Attended

Child's / Young person's GP


Reason for referral

GDPR Statement

Rossendale Hospice respects you and your data. For more details on how we securelyt store your personal information, please visit If you would like to speak to someone about how we process your data please contact We will never pass your details on to any third-party for marketing purposes.

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