GRIT Referral Form
Please complete this form and provide as much information as possible if you would like to access GRIT's 1:1 coaching or group programme services. There are 3 pages in total and it will take approximately 10 minutes to complete. **Once submitted, we will be in contact with you to discuss your next steps - this may take up to 7 working days**
PLEASE NOTE: We are unable to deal with emergency enquires. If you need urgent advice, please contact your GP (Doctor) or the 111 Service.
Who is completing this form?
*
Self Referral (I am the Young Person wanting to access the services)
School (I am a teacher or representative at the Young Person's school)
Parent / Carer
GP (Doctor)
Wellbeing Practitioner
CAMHS
Other
If you have ticked 'other', please can you give us further information on your position, title or service:
Your Contact Details (Young Person)
If you are completing this form on behalf of a young person, please can you ensure they are with you at the time of writing so you can answer the questions from their point of view.
Your Name (Young Person)
*
First Name
Last Name
Your ID Number (only if known - it will start with the letters Con - leave blank otherwise)
Your Email address (Young Person)
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Your Address (Young Person)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referrer Details
If you are referring the Young Person, it is important we know your name and contact details too. Thank you.
Referrer's Name (if referring the Young Person)
First Name
Last Name
Referrer's Email address (if you are referring the Young Person)
example@example.com
Your Parent / Carer Details
Please let us know your parent or carer contact details. It is important we have them, but if you would prefer we didn't contact them regarding the support you receive from GRIT, please let us know by checking the box below.
Parent / Carer Name
*
First Name
Last Name
Parent / Carer Email
*
example@example.com
Parent /Carer Phone Number
*
Please enter a valid phone number.
Please do not contact my parent / carer with regards to the support I receive from GRIT. ** I am aware however, that if there is an emergency you may need to contact them.
Emergency Contact
It is important that we can contact someone on your behalf if there was an emergency. Can you please let us know who this would be below. **Please note we will only contact them in an emergency**
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Emergency Contact Email
*
example@example.com
What is their relationship to you?
*
Back
Next
About You (Young Person)
If you are completing this form on behalf of a young person, please can you ensure they are with you at the time of writing so you can answer the questions from their point of view.
Please let us know your date of birth including year
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-
Day
-
Month
Year
Date
What is your gender?
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Male
Female
Prefer not to say
What are your pronouns?
*
He/Him
She/Her
They/Them
Other
What is your ethnicity?
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English/Welsh/Scottish/Northern Irish/British
Irish
Gypsy or Irish Traveller
Roma
White and Black Caribbean
White and Black African
White and Asian
Mixed/Multiple ethnic groups
Asian/Asian British
Indian
Pakistani
Bangladeshi
Chinese
Black/Black British
African
Caribbean
Arab
Which GP (Doctor) Surgery do you attend? If you are unsure, please ask your parent or carer
*
Ashwell Surgery
Baldock Surgery
Bancroft Surgery
Birchwood Surgery
Courtenay House Surgery
Garden City Surgery
Nevells Road Surgery
Portmill Surgery
Regal Chambers Surgery
Sollershot Surgery
Whitwell Surgery
Other - I live outside of Hitchin or Letchworth
What is your school or employment status?
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Full Time Student
Part Time Student
Not currently attending school
Full Time Employment
Part Time Employment
Unemployed
If you are school aged, which school do you attend?
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Bancroft Centre
Brandles
Fearnhill School
Highfield School
Hitchin Boys School
Hitchin Girls School
Kingshott
Knights Templar
The Priory
Samuel Whitbread Academy
St Christophers
St Francis
Other - my school is not listed here or I go to school outside of Hitchin or Letchworth
What year are you in at school (if applicable)
Year 5
Year 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Year 13
Back
Next
About how you are feeling and the support you require
Please complete this next section carefully. Supporting you to access the right services is very important to us. **If you are completing this on behalf of a young person, please ensure you have their consent before continuing.
What type of support do you require?
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One to one support. I would like to talk to someone confidentially about the way I am feeling
Group support. I would like to join a group with other young people that combines physical activity to understand why I feel the way I do
I am unsure what I need, please can you advise or recommend
What are you hoping to achieve by working with GRIT? What is your goal?
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Tell us about what you have been experiencing and how you have been feeling recently, including any challenges you have had
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On a scale of 1 - 10 how do feel about your experience of your education? (including academic performance, missed days of school).
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Not confident
1
2
3
4
5
6
7
8
9
Confident
10
1 is Not confident, 10 is Confident
On a scale of 1 - 10 how do feel about your relationships outside of school? (friendships / family etc)
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Not confident
1
2
3
4
5
6
7
8
9
Confident
10
1 is Not confident, 10 is Confident
On a scale of 1 - 10 how do feel about managing your moods (anxiety, depression, anger)?
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Not confident
1
2
3
4
5
6
7
8
9
Confident
10
1 is Not confident, 10 is Confident
On a scale of 1 - 10 how do feel about your appearance?
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Not confident
1
2
3
4
5
6
7
8
9
Confident
10
1 is Not confident, 10 is Confident
On a scale of 1 - 10 how do feel about your relationship with food?
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Not confident
1
2
3
4
5
6
7
8
9
Confident
10
1 is Not confident, 10 is Confident
On a scale of 1 - 10 how do feel about your relationship with drugs / alcohol?
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Not confident
1
2
3
4
5
6
7
8
9
Confident
10
1 is Not confident, 10 is Confident
Do you vape or smoke cigarettes, and if so, how regularly?
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Never
Occasionally
Sometimes
Often
Everyday
Do you self harm, and if so, how regularly?
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Never
Occasionally
Sometimes
Often
Everyday
Have you been previously supported by or are you being supported by any other services or agencies such as social care, CAMHS, mental health care team? Please let us know the details below. Please mark as 'no' if this does not apply.
*
Have you been diagnosed with or referred for an assessment for neurodiversity or additional needs?
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No
Austim
ADHD
Dyslexia
Dyspraxia
Other
Have you had any admissions to hospital because of a mental health problem?
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Yes
No
If you answered yes to the above question, can you provide further details:
Do you have any medical problems? (Such as diabetes, heart disease, epilepsy?)
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Yes
No
If you answered yes to the above question, can you provide further details:
Are you currently taking any medication?
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Yes
No
If you answered yes to the above question, can you provide further details:
Is there any additional information we need to know for you to access our services? e.g. language, disability, access issues? Please mark as 'no' if this does not apply.
*
NOTE: Data Protection and Confidentiality. GRIT and the NHS (a strategic partner of the charity) adheres to the Data Protection Act 2018 principles of good information handling and the EU General Data Protection Regulation 2018. Please indicate below if you consent to us collecting, recording and processing your personal data for the purpose of providing you with support and to ensure your health, safety and wellbeing. We will use your information appropriately and in line with our Privacy Policy. Our Privacy Policy: Your details will not be shared with anyone else without your consent. If you have any concerns or questions about how your personal data is collected and used, please email us at hello@gritcharity.org. Please note that without your consent, you will not be able to submit this form and access the GRIT services. Where information is given in confidence that NHS believes poses a risk to the client, a risk to other people, a risk to the safety and welfare of a child, or is against the law, we reserve the right to disclose that information to a relevant third party.
Do you consent to us collecting, recording, processing and contacting you using your personal data (e.g. phone number, email address) for the purpose of providing you with support and to ensure your health, safety and wellbeing?
*
I consent
We occasionally capture photos and videos of our activities and events including those which may feature you. These visuals help us to celebrate your contributions and share the impact of our work with others. Before we proceed with using any photos or videos featuring you, we want to ensure you are comfortable with this. Do you consent to us using photos and videos of you on our website, social media, newsletters and other promotional materials
I consent
I do not consent
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