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. We will then keep it in our own storage. We will process all data in line with relevant laws and principles.


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 are you referring?*
Do you have consent from the person you are referring?*
Does the person you are referring consent for us to update you on the outcome of the referral?*
How old are you?*
How old is 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 0151 482 6291 or email us at knowsley.info@cgl.org.uk.

Full name*
Date of birth*
Sex at birth*


Your gender identity


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

What do you use to describe your gender?
Do you identify as trans?
What are your pronouns?

Contact information

Do you have a fixed address?*
Address*
How would you like us to contact you? (Please choose all that apply)*

Please choose at least one option.


How we can help you


Your patient or client's details

Full name*
Date of birth*
Sex at birth*


Gender identity


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

What does your patient or client use to describe their gender?
Does your patient or client identify as trans?
What are your patient or client's pronouns?

Your patient or client's contact details

Does your patient or client have a fixed address?*
Address*
How would your patient or client like us to contact them? (Please choose all that apply)*

Please choose at least one option.


How we can support them

Your details

Full name*

Full name*
Date of birth*
Gender
What is your ethnic group?
Which of the following best describes your White background?
Which of the following best describes your Mixed or Multiple ethnic groups background?
Which of the following best describes your Asian or Asian British background?
Which of the following best describes your Black, African, Caribbean or Black British background?
Which of the following best describes your background?

Contact information

Current address*
How would you like us to contact you? (Please choose all that apply)*

Do you need a translation service?*


How we can help you

What support would you like from the service?*

Your details

Full name*
What is your relationship to the young person?*

Does the young person’s parent(s)/carer(s) know about this referral?*
Would you like feedback on the outcome of this referral?

Other agencies

Are you aware of any other agencies working with the young person?

Please provide details of these agencies below, and include as many details as possible.


If the young person is involved with social care, please specify the type of support.

Substance use

Risks

Other than the substance use, do you feel this young person is at risk of harm from themselves?*
Do you feel the young person is at risk of harm from others?*
Do you feel the young person may pose a risk to others?*

Young person's details

Full name*
Date of birth*
Gender*
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?
Address *
How would your patient or client like us to contact them? (Please choose all that apply)*

Is the young person attending school or college?
Does the young person give consent for us to contact their school or college?
Is the young person pregnant?*
Does the young person consider themselves to have a disability?
Does the young person need an interpretor?
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