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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, WokinghamHere4YOUth, Oxfordshire
ABOUT YOU AND YOUR ORGANISATION.
Your name (Required)
Your surname (Required)
Your role (Required)
Agency/organisation name (Required)
Postcode (Required)
Email address (Required)
Telephone (Required)
ABOUT YOUR CLIENT.
First name(s) (Required)
Surname (Required)
Client's date of birth (Required)
Email address
Client's telephone (Required)
Client's address Please mark NFA if the client is of no fixed address (Required)
Client's postcode.
Who does your client live with?
PhoneTextEmailLetter Other. Please specify:
YesNo If no, please give details:
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
HEALTH INFORMATION
How can we help your client?
YesNo If yes, which one:
YesNo If yes, please give details:
CannabisAlcoholNew psychoactive substancesNitrous OxideSolventsCocaineCrack cocaineMDMAKetamineAmphetamine/speedHeroin/opiatesPrescribed medicationsOther Please give details including how much and how often the substance is being used.
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
GP's address
GP's postcode
Personal information is important to us and we will keep it confidential. Occasions where we may need to share information are outlined in our privacy and confidentiality policy. You can read our privacy policy here, or alternatively you can ask for a copy from us.
Date of submission
The young person named in this form has consented to be contacted by Cranstoun.I Confirm
Submit this form and we will contact you to arrange an appointment at a time and place that suits you.
Thank you for reaching out to Cranstoun.
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