This form is for professionals supporting children and young people who need support for a range of issues including alcohol and other drugs.
What service location would you like to refer into? —Please choose an option—Here4YOUth, DudleyHere4YOUth, SuttonHere4YOUth, WorcestershireHere4YOUth, BuckinghamshireHere4YOUth, WokinghamHere4YOUth, Oxfordshire
ABOUT YOU AND YOUR ORGANISATION.
Your name (Required)
Your surname (Required)
Your role (Required)
Agency/organisation name (Required)
Email address (Required)
ABOUT YOUR CLIENT.
First name(s) (Required)
Client's date of birth (Required)
Client's telephone (Required)
Client's address Please mark NFA if the client is of no fixed address (Required)
Who does your client live with?
How should we contact your client? Select all that apply
PhoneTextEmailLetter Other. Please specify:
Can we contact your client at any time?
YesNo If no, please give details:
Can we leave a voicemail?YesNo
Is there another telephone number we should have? Whose number is this?
Client's gender (Required)
—Please choose an option—MaleFemaleOtherPrefer not to say
Client's ethnicity (Required)
—Please choose an option—White BritishWhite IrishWhite OtherWhite & AsianWhite & Black CaribbeanWhite & Black AfricanMixed OtherAfricanCaribbeanBlack OtherBangladeshiIndianPakistaniAsian OtherChineseOther
How can we help your client?
Are they currently at school or college? YesNoWhich one:
Are they a care leaver? YesNo
Do they have a learning disability? YesNoIf yes, please give details:
Are they pregnant?YesNo
Are they using drugs or alcohol? YesNoWhich ones?
Do they need support because someone they know is using drugs? YesNoIf yes, please give details:
Are they at risk of hurting themselves? YesNoIf yes, please give details:
Are they at risk from others? YesNoIf yes, please give details:
Do they have access support needs e.g. mobility or interpreter requirements? If yes, please give details:
GP name Please write 'Not registered' if they do not have a GP
Can we contact the GP? YesNo
Submit this form and we will contact you to arrange an appointment at a time and place that suits you.
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