Referral Form

Hello and welcome to our Children, Young People & Family Service.

We all go through periods in our life when we feel sad, anxious, or stressed. When these feelings start to get in the way of our daily life or impact upon our relationships, we may need some extra support, so it is great that you are here today, taking the next step in getting help.

• If you are aged between 13-18 years you may wish to complete this form on your own. We would encourage you to involve a parent or carer as it might be helpful to let them know how you are feeling.

• If you are under 13 years, a parent or carer will need to complete this form on your behalf.

To help us understand how you are feeling and to get you the right support, please complete the form below.

We would appreciate that you take the time to complete the questionnaire as this will give us a better understanding of the difficulties you are experiencing. We are aware this will not tell us the full story but is a great starting point. It takes an average of 10 minutes to complete, however, you may wish to give yourself more time if you are finding it difficult to think about your emotions at the moment.

If you don’t feel able to complete the questionnaire, you can skip it and someone from our team will contact you in the next couple of days to talk to you.

I am a:*

Young person aged 13 years or over

Parent/carer

Do you attend one of our schools?:*

We sometimes need to talk to the Mental Health Lead in your school, this supports our assessment process and enables us to have a full understanding of your difficulties and the support available to you in school. If you’re happy for us to speak to your school, please consent by ticking the box below.

I consent:*

Yes

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Prefer not to Say

Other

Address Line 1:*

Town/City:*

Postcode:*

Mobile Number:*

Permissions to ring mobile number:*

Yes

No

Do you give consent for us to leave a message on this number? This consent will include if another person answers your phone:*

Yes

No

Permission to text:*

Yes

No

Email:

Permission To Send Email:

Yes

No

Home number:

Do you give consent for us to leave a message on this number? This consent will include if another person answers your phone:

Yes

No

Other Number:

Preferred method of communication:*

Ethnicity:*

GP Surgery:*

Parent/carer Name:

Parents Email Address:

Parents Mobile Number:

Can we contact your parent/carer:

Yes

No

Where did you hear about us:*

Referral Reason:*

What type of help do you think you might need? Please provide information you think we should know:*

I would like to receive a confirmation of my self-referral to the email address I specified above:

Yes

No

I accept terms and conditions:*

Yes

No

www.alliancepsychology.com/wp-content/uploads/2019/12/Privacy-Notice-for-clients-v3.pdf

Please complete the captcha

Referral Form

Hello and welcome to our Children, Young People & Family Service.

Young Persons Details

Further Details

Referral Details