This form is safe and secure. Your details are protected by encryption and they are confidential - we will only share them with professionals outside of Change Grow Live if we think someone is at risk of harm.


We will store your information for a short time within the secure Formstack database. We will then keep it in our own storage. Only people who need to see your details will have access.


You must have consent from the young person to give their details.


Please make sure you complete any questions marked with an asterix (*) as we need these details to get in contact with the person you are referring.

Referrer details

What is your role?*

Has the young person consented to this referral?*
Have the young person’s parent(s)/carer(s) been informed of the referral?*
Would you like feedback on the outcome of this referral?

Other agencies

Are you aware of any other agencies involved 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

From this point onwards, please answer all questions on behalf of the person you are referring (do not provide information about yourself).

Date of birth*
Gender*
Please select one option
Address

Please make sure you provide at least one contact method.

Do they consent to us calling them?*
Do they consent to us emailing them?*
Which, if any, method of contact is the young person happy for us to use to contact them? (Tick 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?
Form secured by Formstack
Form secured by Formstack