The Youth Wellbeing Project Referral and Consent Form

Social Services
Is the Young Person a looked after child? (If no, please move to the Housing section)*

YesNo
Social Worker Name

First NameLast Name
Local Authority
Phone Number
Email
example@example.com
Housing
What type of accommodation does the young person live in? (supported accommodation, with parents/guardian, in foster care etc.)*
Housing placement Manager & phone number: (if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

	None of the time	Rarely	Some of the time	Often	All the time
I have been feeling optimistic about the future.
I have been feeling useful.
I have been feeling relaxed.
I have been dealing with problems well
I have been thinking clearly.
I have been feeling close to other people.
I have been able to make up my own mind about things

NCG Youth Wellbeing Project (ages 11-21)