This form is safe and secure. The information you provide is confidential and protected by encryption. We will only share information with professionals outside of Change Grow Live if we think someone is at risk of harm.


We will store this referral for a short time within the secure Formstack database. It will then be kept in just our own storage. Only people within CGL involved with the assessment and support of the person referred will have access.


Please make sure you complete any questions marked with an asterisk (*) as we need these details to complete the next steps of your referral.


Who is this referral for?*
Do you have consent from the person you are referring?*

Please only complete a referral on someone's behalf if you have their consent. If you have any questions, please give us a call on 0203 227 4950 or email us on Some.Space@cgl.org.uk.

Your details

Date of birth*


Gender identity


We are asking these questions to make sure our service meets everyone's needs. 

What do you use to describe your gender?


Contact information

Do you have a fixed address?*
Address*
What is your preferred contact method(s)?*
Please provide an address that you can be contacted at*

Do you need a translation service?*


How we can help you?

Please provide as much detail as possible
Are you currently receiving any professional psychological support regarding this matter? *


Your details

What is your relationship to the person you are referring?*


Details of the person you are referring

Date of birth*
Sex at birth


Gender identity

We are asking these questions to make sure our service meets everyone's needs. 

What do they use to describe their gender?
Do they identify as trans?
What are their pronouns?


Ethnicity

What is their ethnic group?
Which of the following best describes their white background?
Which of the following best describes their mixed or multiple ethnic groups background?
Which of the following best describes their Asian or Asian British background?
Which of the following best describes their black, African, Caribbean or Black British background?
Which of the following best describes their background?


Contact information

Do they have a fixed address?*
Address*
What is their preferred contact method(s)?*
Please provide an address that they can be contacted at*


How we can help the person you are referring?

Please provide as much detail as possible
Are they currently receiving professional psychological support regarding this matter?*

Risks

Does the person you are referring believe they are at risk of harm from the substance user/s?*
Does the person you are referring believe the substance user/s pose a risk to others?*