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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?

    ABOUT YOU AND YOUR ORGANISATION.

    ABOUT YOUR CLIENT.

    Who does your client live with?

    How should we contact your client? Select all that apply

    PhoneTextEmailLetter

    Can we contact your client at any time?

    YesNo

    Can we leave a voicemail?YesNo

    Is there another telephone number we should have?
    Whose number is this?

    Client's gender (Required)

    Client's ethnicity (Required)

    HEALTH INFORMATION

    How can we help your client?

    Are they currently at school or college? Which one:

    Are they a care leaver?

    Do they have a learning disability? If yes, please give details:

    Are they pregnant?

    If they use substances, which ones do they use? (select all that apply) Please give details including how much and how often the substance is being used.

    Do they need support because someone they know is using drugs? If yes, please give details:

    Are they at risk of hurting themselves? If yes, please give details:

    Are they at risk from others? If yes, please give details:

    Do they have access support needs e.g. mobility or interpreter requirements?

    Can we contact the GP?

    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.

    The young person named in this form has consented to be contacted by Cranstoun.

    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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