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?*
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 01709 917651.

Date of birth*
Gender*
Current address*

How would you like us to contact you?*
Do you need a translation service?
What support would you like from the service?*

Your details

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

Date of birth*
Gender*
Address

Which contact method(s) would they prefer?*
What is the care status of the young person?*
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 need an interpretor?
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