Young Person Professional Referral Form

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)

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?

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

HEALTH INFORMATION

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

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.

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.