Youth Services CIC

Make a referral

Self / Parent-Carer Referral

For young people referring themselves, and for parents and carers referring their child. Tell us what’s happening in your own words. There are no wrong answers.

1 About you
I am…
Please tell us who is making the referral.
Please fill in this field.
Leave blank if you are the young person.Please fill in this field.
Please fill in this field.
Please enter a valid email address.
Please choose an option.
For example: weekdays after 3pm.Please fill in this field.
2 About the young person
Please fill in this field.
Please fill in this field.
Or tell us if they are not currently in education.Please fill in this field.
Please fill in this field.
Please choose an option.
3 What’s happening

Tell us as much or as little as you feel comfortable with. We’ll talk it through with you.

What would you like help with? Choose all that apply.
Please choose at least one option.
For example: what you’ve noticed, how long it’s been happening, what has already been tried.Please fill in this field.
What would things look like if they were going better?Please fill in this field.
Would you like to talk about counselling or therapeutic support?We have in-house counsellors. We’ll discuss what is suitable and available.
Please choose at least one option.
For example: school staff, social worker, health services, youth justice.Please fill in this field.
4 Consent
Please confirm to continue.
Please confirm to continue.

Fields marked * are required.

Referral sent. Thank you.

We’ve received your referral and will be in touch to talk it through. If a young person is in immediate danger, call 999 or go to A&E.

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