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)
—Please choose an option—Here4YOUth, DudleyHere4YOUth, SuttonHere4YOUth, WorcestershireHere4YOUth, BuckinghamshireHere4YOUth, 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?

How should we contact you? Select all that apply (Required)PhoneTextEmailLetter Other. Please specify:

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

Can we contact you at any time?YesNoIf no, please give details:

Can we leave a voicemail?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?

Are you currently at school or college? YesNoWhich one:

Are you a care leaver? YesNo

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

Are you pregnant?YesNo

Are you using drugs or alcohol? YesNoWhich ones?

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

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

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

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

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.