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. Only people who need to see the referral information 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?*
Which service are you referring to?*
How old are you?*
How old is the person you are referring?*
Is your patient or client a student at the University of Manchester or Manchester Metropolitan University?*
Do you have consent from the person you are referring?*

Please only make a referral on someone's behalf if you have their consent. 

Date of birth*


Your gender identity


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

Which of the following best describes how you think of yourself?*
Is your gender identity the same as the gender you were given at birth?*
Which of the following best describes how you think of yourself?*
What are your pronouns?
Are you or your partner pregnant? *
Have you recently been discharged from hospital? *
Have you recently been released from prison? *
Have you had any suicidal thoughts in the last three months? *

Contact information

Do you have a fixed address?*
Address*


How we can help you

How would you like us to contact you? Please select at least one option.*


Your patient or client's details

Date of birth*


Gender identity


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

Which of the following best describes how your client thinks of themself?
Is your client's gender identity the same as the gender they were given at birth?*
Which of the following best describes how your client thinks of themself?
What are your patient or client's pronouns?
Is the person you’re referring or their partner pregnant? *
Has the person you’re referring recently been discharged from hospital? *
Has the person you’re referring recently been released from prison? *
Has the person you’re referring had suicidal thoughts in the last three months? *

Your patient or client's contact details

In this section please answer all questions on behalf of the person you are referring.

Does your patient or client have a fixed address?*
Address*


How we can support them

How would your patient or client like us to contact them?*
Please choose at least one option.

Your details

Have you worked with our service before?*
Date of birth*
Are you a University of Manchester student wishing to book a SU drop-in appointment?
Does your parent or guardian know you are contacting us?*
Which of the following best describes how you think of yourself?*
Is your gender identity the same as the gender you were given at birth?*
Which of the following best describes how you think of yourself?
Current address*

How would you like us to contact you?*
Please choose at least one option.
Do you have a disability?*
Are you a Care Leaver?*
Do you need a translation service?
Do you go to school or college?
Are you happy for us to contact your school or college?
What support would you like from the service?*

About you

What is your relationship to the young person?*

Does the person with parental responsibility know about this referral?*
Would you like feedback on the outcome of this referral?

About the young person

Has the young person you’re referring worked with us before?
Are you aware of any other agencies working with the young person?
What does the young person need support with?

Substance use

Risks

Other than the substance use, do you feel this young person is at risk of harm from themselves?*
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

Date of birth*
Has the person with parental responsibility given consent for this referral?
Which of the following best describes how the young person thinks of themself?*
Is their gender identity the same as the gender they were given at birth?
Which of the following best describes how they think of themself?
Address *

Which contact method(s) would they prefer?*
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?*
Is the young person a Care Leaver? *
Does the young person need an interpretor?