Self Referral Form

Hello and welcome to Youth Talk.

At Youth Talk (YT) we’re here to listen to and support you – about whatever’s worrying you. We offer confidential help to young people aged 13 to 25 years (last referral age 24th birthday) in St Albans and surrounding areas. See our website for details about the help we offer and our catchment area.

Please complete this form yourself, or telephone YT and someone will help you with this. We are open Mondays to Thursdays from 10.00 am to 7.00 pm, and Fridays from 10am to 5.00 pm. We will respond by phone within three working days.

* denotes a mandatory field.

Personal Details

Title:

First Name:*

Last Name:*

Date of Birth:*

Gender:*
Male
Female
Other
Prefer not to say

Ethnicity:*

Religious beliefs:*

Sexuality:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Email:*

Mobile Phone Number:*

Occupation:
School (please select from drop down menu)
College or University (please specify)
Work within St Albans & District (please specify)
Other (please specify)

School/college details:

If College or University, please specify:

If working or other, please specify:

GP name (if known):

GP Practice Name:*

In your own words describe why you want to come to YT:*

Are you worried about harming yourself or concerned about anything else? If so, please provide details:

On which weekdays and at what times will you be able to attend weekly appointments (the more flexible you are the sooner we may be able to see you)?*

Do you have any special needs (eg a disability that might affect access)?

Are you currently receiving counselling or any other professional help? If so, please specify:

How did you hear about YT?:*

Have you been to Youth Talk before?:*
Yes
No

Do you know anyone who attends/has attended YT’s services or who works here? If so, please specify.

Permission to Contact

We will need to contact you by phone and will send information and appointments by email (be sure to check your spam folder) and SMS (text).

The main method of contact is email - please remember to check these

Permission to send SMS?:*
Yes
No

Permission to leave voicemail on mobile phone?:*
Yes
No

In order to provide our service, we need to hold some details about you. Information about our data policy is available on our website. By submitting this form you are agreeing to Youth Talk holding your information.

Please complete the captcha