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This form is for children and young people who would like support for a range of issues including alcohol and other drugs. If you are the concerned parent of a young person, please contact us directly.
What service location would you like to refer into? (Required) —Please choose an option—Here4YOUth, DudleyHere4YOUth, SuttonHere4YOUth, WorcestershireHere4YOUth, WokinghamHere4YOUth, Oxfordshire
ABOUT YOU
First name(s) (Required)
Surname (Required)
Date of birth (Required)
Email address
Telephone (Required)
Address (Required) Please mark NFA if you are of no fixed address
Postcode
Who do you live with?
PhoneTextEmailLetter Other. Please specify:
Is there another telephone number you would like to give us?
Whose number is this?
YesNo If no, please give details:
YesNo
Gender (Required)—Please choose an option—MaleFemaleTransgenderNon-binaryPrefer not to say
Ethnicity (Required)—Please choose an option—White BritishWhite IrishWhite OtherWhite & AsianWhite & Black CaribbeanWhite & Black AfricanMixed OtherAfricanCaribbeanBlack OtherBangladeshiIndianPakistaniAsian OtherChineseOther
HEALTH INFORMATION
How can we help you?
YesNo 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 you have access support needs e.g. mobility or interpreter requirements? Please give details:
Your GP (Required) Please write 'Not registered' if you do not have a GP (Required)
Can we contact your 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
Submit this form and we will contact you to arrange an appointment at a time and place that suits you.
Confirm that you consent to be contacted by Cranstoun I agree
Thank you for reaching out to Cranstoun.
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