Preferred pronouns
NHS number (if known)
Email address of the person being referred
Please provide an email address or phone number of someone we can contact if we cannot get hold of you *
Please provide an email address or phone number of someone we can contact if we cannot get hold of the young person *
As you selected 'other', please tell us what relationship the person is to you *
As you selected 'other', please tell us what relationship the person is to the young person *
As you selected 'other', please tell us how you heard about this service
Please provide any information on how best we can communicate with you *
Please provide any information on how best we can communicate with them *
What is your accommodation status? * Please select a choice from the dropdown menu Living with parents or other relatives Living independently in settled accommodation Living independently in unsettled accommodation Living independently with no fixed abode Supported housing Living in care Living in secure care
What is the young person's accommodation status * Please select a choice from the dropdown menu Living with parents or other relatives Living independently in settled accommodation Living independently in unsettled accommodation Living independently with no fixed abode Supported housing Living in care Living in secure care
What is your education status? * Please select a choice from the dropdown menu Educated at mainstream school Alternative education Excluded from school temporarily Excluded from school permanently Persistent absentee Apprenticeship of training Economically inactive - caring role Economically inactive - health issue Unpaid work Regular employment Not in employment, education or training Prefer not to say
What is the young person's education status * Please select a choice from the dropdown menu Educated at mainstream school Alternative education Excluded from school temporarily Excluded from school permanently Persistent absentee Apprenticeship of training Economically inactive - caring role Economically inactive - health issue Unpaid work Regular employment Not in employment, education or training Prefer not to say
What is your ethnicity? * Please select a choice from the dropdown menu White British African Albanian Any other group Arab Asian and Chinese Baltic Estonian/Latvian/Lithuanian Bangladeshi or British Bangladeshi Black and Asian Black and Chinese Black and White Black British Bosnian British Asian British or mixed British Buddhist Caribbean Caribbean Asian Chinese Chinese and White Commonwealth (Russian) Indep States Cornish Croatian Cypriot (part not stated) East African Asian English Ethnic category not stated Filipino Greek Greek Cypriot Gypsy/Romany Hindu Indian or British Indian Italian Iranian Irish Traveller Israeli Japanese Jewish Kashmiri Kosovan Kurdish Latin American Malaysian Mauritian/Seychellois/Maldivian/St Helena Mid East (excl Israeli, Iranian & Arab) Mixed Asian Mixed Black Mixed Irish and other White Moroccan Muslim Nigerian North African Northern Irish Other Asian or Asian unspecified Other Black or Black unspecified Other White European/European unsp/Mixed European Other Mixed or Mixed unspecified Other mixed White Other republics former Yugoslavia Other White or White unspecified Pakistani or British Pakistani Polish Punjabi Scottish Serbian Sikh Sinhalese Somali South and Central American Sri Lankan Tamil Turkish Turkish Cypriot Ulster Scots Vietnamese Welsh White and Black Caribbean White and Black African White and Asian White Irish Unknown
What is the young person's ethnicity * Please select a choice from the dropdown menu White British African Albanian Any other group Arab Asian and Chinese Baltic Estonian/Latvian/Lithuanian Bangladeshi or British Bangladeshi Black and Asian Black and Chinese Black and White Black British Bosnian British Asian British or mixed British Buddhist Caribbean Caribbean Asian Chinese Chinese and White Commonwealth (Russian) Indep States Cornish Croatian Cypriot (part not stated) East African Asian English Ethnic category not stated Filipino Greek Greek Cypriot Gypsy/Romany Hindu Indian or British Indian Italian Iranian Irish Traveller Israeli Japanese Jewish Kashmiri Kosovan Kurdish Latin American Malaysian Mauritian/Seychellois/Maldivian/St Helena Mid East (excl Israeli, Iranian & Arab) Mixed Asian Mixed Black Mixed Irish and other White Moroccan Muslim Nigerian North African Northern Irish Other Asian or Asian unspecified Other Black or Black unspecified Other White European/European unsp/Mixed European Other Mixed or Mixed unspecified Other mixed White Other republics former Yugoslavia Other White or White unspecified Pakistani or British Pakistani Polish Punjabi Scottish Serbian Sikh Sinhalese Somali South and Central American Sri Lankan Tamil Turkish Turkish Cypriot Ulster Scots Vietnamese Welsh White and Black Caribbean White and Black African White and Asian White Irish Unknown
Where would you like to be seen? *
Where would the young person like to be seen? *
Please provide as much detail as possible about this risk *
In the box below please record any additional concerns for the young person, e.g. mental health/self harm, child sexual exploitation, safeguarding, attendance at A&E due to drug/alcohol use, homelessness, NEET, drug debt, domestic violence, involved in offending (Youth Justice/Probation only, details of offense, date order/intervention ends, pregnancy, or parental drug/alcohol use.
Please tell us if there are any other agencies/professionals involved with the young person
Referrer organisation/source *
Referrer email address *
Referrer phone number *
