Therapeutic Direct Work Form

Referral Submitted

Thank you - your Therapeutic Direct Work referral has been received by the HAPii team.
We will be in touch within 2 working days to discuss suitability, scope, consent, and next steps.

Referral Details

Date of Referral *

Preferred Contact Method *

Level of Urgency *

Relevant Deadline / Target Date

Referring Person / Organisation

Name *

Position / Role *

Organisation / Agency *

Contact Phone *

Contact Email *

Child / Young Person Details

Name, Date of Birth & Age *

Current Placement / Living Arrangement *

Legal Status / Care Order

Communication, Disability, Cultural or Access Needs

Family, Carers & Network

Birth Parent(s) / Legal Guardian(s)

Current Carer(s) / Key Adults *

Siblings / Significant Relationships

Current Contact / Access Arrangements

Therapeutic Direct Work Requested

Play-Based Therapeutic Direct Work Relational, developmentally sensitive work using play, creativity, and connection. Attachment-Focused Direct Work Support focused on safety, trust, connection, relationship patterns, and repair. Trauma-Responsive Direct Work Work paced around regulation, triggers, safety, and the child's lived experience. Emotional Regulation & Coping Support Practical, relational support for understanding feelings, needs, and coping strategies. Preparation / Transition Support Support around contact, placement moves, reunification, endings, or other transitions. Bespoke Therapeutic Support Package A tailored blend of direct work, carer guidance, and professional consultation.

Preferred Delivery *

Estimated Number of Sessions

Therapeutic Goals & Questions

Reason for Referral *

Desired Outcomes / Therapeutic Goals *

Child's Views / Wishes / Readiness

Background & Current Presentation

Relevant Attachment / Caregiving History

Known or Suspected Trauma / Adversity

Current Presentation / Needs *

Strengths, Interests & What Helps

Current Supports & Previous Work

Current Professional Supports

Previous Direct Work / Therapy / Interventions

Safeguarding & Legal Context

Immediate Risk / Safety Concerns? *

Court / Legal Proceedings Involved?

Risk / Safeguarding Details

Practical Arrangements

Location / Online Platform

Availability / Preferred Times

Carer / Parent / Professional Involvement

Documents Available

Care Plan Assessment / report Therapeutic report School report Court order / direction Consent forms Other

If other, please specify

Preferred Consultant

Dr Lisa O'Reilly Founder & Director | Guardian ad Litem | Play Therapist | Attachment Researcher Charlotte Lyne Child & Adolescent Psychotherapist | Play Therapist | Clinical Supervisor Dr Katie O'Donoghue Art Psychotherapist | Chartered Psychologist (BPS) Mel Shanley Guardian ad Litem | Medical Social Worker | Trauma Specialist No preference Please recommend the best match for this referral

Declaration

I confirm I have authority to make this referral and that consent, information-sharing permissions, and safeguarding arrangements are in place or will be clarified before therapeutic direct work begins. I understand HAPii may request further information before confirming suitability and scope.

Additional Notes

Signature (Full Name) *

Date *

HAPii Therapeutic Direct Work Form

Referral Submitted