N.O.W.S National Online Wellbeing Service

School registration

School name

School lead / referrer name

School lead / referral email address

Please include (SENCO/ Pastoral / Mental Health lead)

Academy trust name

School contact number

School type

Quadrant area

Basildon & Brentwood (inc Wickford)
Rochford & Castle Point (inc Canvey)
Mid Essex (inc Chelmsford)
North East Essex (inc Colchester)
Southend
Thurrock
West Essex

Referral type

1-2-1 virtual 6 weeks programme
1-2-1 virtual 12 weeks programme
Transition with resilience workshop
Mediation workshop
6 week emotional resilience & wellbeing workshop
1-2-1 therapeutic coaching & mentoring
Certified emotional wellbeing & mental health training

Address for referral for 1-2-1 or school address for other services

Contact number for referral for 1-2-1 or school address for other services

Email address number for referral for 1-2-1 or school address for other services

Title

Mr
Mrs
Ms
Miss
Master
Other

First name (including any middle names)

Surname

Ethnicity of referral

Gender of referral

Male
Female
Other
Prefer not to say

DOB of referral or year group

DOB - Date/Month/Year or year group

Referral reasons

Please provide main concerns / worries that are causing emotional / mental stress and how long has it been going on for?