Referral Form

Welcome to the first step in getting support from us

To allow us to offer you an appointment we would like the following info

Form takes about 5 minutes to fill in

This form is split into two parts – part A & part B

If you are seeking support for yourself, just fill out part A ONLY

OR

If you are filling the form out on behalf of somebody else you need to fill in BOTH part A and part B

Title:*

First name:*

Last name:*

Address Line 1:*

Address Line 2:

Town/City:*

County:

Postcode:*

Mobile telephone number:

Permission to send you texts:

Yes

No

Permission to leave voicemails:

Yes

No

Email address:

Permission to be contacted by email:

Yes

No

We will use your mobile number and possibly email to communicate important information about our service, such as appointment times. We do not use your contact details for any other purpose.

Date of birth:*

Do you live / work / study in Bath & North East Somerset:*

Yes

No

Do you consider yourself to have a disability?:*

Yes

No

Prefer not to say

If, Yes, is it:

If you have any access needs, please describe what support you might need:

Gender:*

Is your gender the same as the sex you were assigned at birth?*

What are your pronouns?

What is your sexual orientation?*

What is your ethnic origin?*

Which of the following categories, if any, describes your situation?

If in education, what school / college / university do you attend?

I understand that OTR only collect the relevant information for the services they will provide me, and that they will respect my wishes and rights in regard to the storage of my data, and I have a right to be forgotten. I also understand that my information will be stored safely and securely, and I consent to OTR using my personal details so I can engage in the services provided and so these services can be assessed and improved.

I consent:*

Yes

No

What service would you like to access?

Where would you like to access support?

Bath

MSN

Keynsham

Tell us what is wrong?*

Your first name:

Your last name:

Your relationship to the young person:

Your contact telephone number:

Your email address:

We will communicate directly with the young person to make arrangements for appointments unless you select the box – then we use the contact details you have provided above:

Yes

Is the young person aware that this referral is being made? (if not we would encourage this conversation to take place):

Yes

No

Reason for referral (this is the same question as ‘tell us what us wrong’ in Part A):

Does the young person present any risky behaviour?

Please tick the box if you’d like to receive our email newsletter:

Yes

Please complete the captcha

Self Referral Form

Part A – details of the young person

Part B – for parents, professionals, friends and other agencies