Young Person Self-referral Form

    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)

    ABOUT YOU

    Who do you live with?

    How should we contact you? Select all that apply (Required)PhoneTextEmailLetter

    Is there another telephone number you would like to give us?
    Whose number is this?

    Can we contact you at any time?YesNo

    Can we leave a voicemail?YesNo

    Gender (Required)

    Ethnicity (Required)

    HEALTH INFORMATION

    How can we help you?

    Are you currently at school or college? Which one:

    Are you a care leaver?

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

    Are you pregnant?

    Are you using drugs or alcohol? Which ones?

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

    Do you feel you are at risk of hurting yourself? If yes, please give details:

    Do you feel you are at risk from others? If yes, please give details:

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

    Can we contact your 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.

    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

    Thank you for reaching out to Cranstoun.

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