Self-referral Form - YMCA Wellbeing Service

Please note the following:
- This self-referral form is to be completed only by young people aged 13 - 18 wishing to access our service. (Please note: this referral must be completed by the young person themselves, not parents/carers.)
- If you are a young person below the age of 13, please ask your parent/carer to support you by completing a parent referral form for you on your behalf, which can be found on our website. If you have any queries/problems with this, please get in touch with us by either calling 01392 410530 or emailing us at wellbeing@ymcaexeter.org.uk.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Describe Gender*
Pronouns
Address*

Street Address

Street Address Line 2

CityRegion

Post Code
Contact number*
Please let us know/specify the owner of the above phone number.*
How do you prefer to be contacted?*
We will do our best to reach you using the preferred contact details you provided. If we are not able to reach you using your preferred contact details, we may try other ways to get in touch. Please double-check that your information is accurate and that you are happy for us to contact you via the details provided.
Is there a good time to contact you? If so, please give days and times:*
Can we leave a voicemail on your phone?*

YesNo
Email*
Ethnicity:
(Please tick appropriate box)*

White and Black CaribbeanWhite and Black AfricanWhite and AsianWhite BritishWhite IrishWhite otherIndianPakistaniBangladeshiCaribbeanAfricanOther
If "Other" to any of the above ethnic groups, please specify:*
Please type N/A if "Other" option was not used.
Prefer not to say:
Who is your GP? (Name and Surgery)*
(If unknown, please state unknown)
Do you have a disability?*

YesNo
If yes, please state below:*
Please type N/A if "No" option was not used.

Please put a tick in the box that shows how often each of these things happens to you. There are no right or wrong answers*

	Never	Sometimes	Often	Always
I worry about things
I feel sad or empty
Nothing is much fun anymore
I feel worried when I think someone is angry with me
I worry about being away from my parents
I get bothered by bad or silly thoughts or pictures in my mind
I suddenly feel as if I can't breathe when there is no reason for this
I have to keep checking that I have done things right (like the switch is off, or the door is locked)
I have trouble going to school in the mornings because I feel nervous or afraid
I worry I might look foolish
I worry that bad things will happen to me
When I have a problem, I feel shaky
I have to think of special thoughts (like numbers or words) to stop bad things from happening
I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds)
My heart suddenly starts to beat too quickly for no reason

Out of the above statements, what is most difficult for you at the moment?*
How often is this feeling difficult?*
When and where do you find this most difficult?*
What areas of your life does this impact? *
What would you like to change/be different?*
What kind of support do you think would be most helpful for you?*
Do you feel at risk to yourself?*

YesNo
Do you feel at risk to others?*

YesNo
Do you feel at risk from others?*

YesNo
If you have answered "Yes" to any of the above questions regarding feeling at risk, please give details:*
Please type N/A if you responded "No".
Our Wellbeing Practitioners also offer evidence-based Low Intensity CBT group sessions. Please look at our website for more information on Groupwork. Would you like to be considered for Groupwork?*

YesNo
Have you been referred to this form by a professional?*

YesNo
If yes, please provide details:*
Please type N/A if your response was No to the previous question.
Please let us know if any other professionals (e.g. Social Worker or GP) ARE working with you currently (and if so, what support are they providing?)*
Please type NO if this question is not applicable.
Please let us know if any other professionals (e.g. Social Worker or GP) HAVE worked with you within the last year (and if so, what support did they provide and when was this?)*
Please type NO if this question is not applicable.
Do you consent for your data to be stored, as per the terms on our website?*

YesNo
If you require any additional assistance with completing the referral form, please contact us at 01392 410530 or email us at wellbeing@ymcaexeter.org.uk.
By submitting this form, you confirm that you have read and consented to our Attendance Agreement on our website.*

I confirm
Should be Empty:

Ethnicity: