GRIT Referral Form

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. It will take approximately 5 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 / CarerGP (Doctor)Wellbeing PractitionerCAMHSOther
If you have ticked 'other', please can you give us further information on your position, title or service:

0/8000
How did you hear about us or who recommended you to make this referral?*

SchoolParent / CarerGP (Doctor)CAMHSOther
If you have ticked 'other', please can you give us further information on how you heard about us or who recommended you to make this referral?

0/8000
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 NameLast Name
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

CityState / Province

Postal / Zip Code
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 NameLast 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.
Referrer Details

If you are referring the Young Person, it is important we know your name and contact details too. If you are the Young Person completing this form, you can leave this section blank. Thank you.
Referrer's Name (if referring the Young Person)

First NameLast Name
Referrer's Email address (if you are referring the Young Person)
example@example.com
Referrer's Phone Number
Please enter a valid phone number.
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**
My Emergency Contact is the same as my parent's details above
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com
What is their relationship to you?
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*

DayMonthYear
Date
Which GP (Doctor) Surgery do you attend? If you are unsure, please ask your parent or carer*

Ashwell SurgeryBaldock SurgeryBancroft SurgeryBirchwood SurgeryCourtenay House SurgeryGarden City SurgeryNevells Road SurgeryPortmill SurgeryRegal Chambers SurgerySollershot SurgeryWhitwell SurgeryOther - I live outside of Hitchin or LetchworthI am unsure of my surgery
If you are school aged, which school do you attend? *If you are not school aged, and do not attend school please click the box at the very end*

Bancroft CentreBrandlesFearnhill SchoolHighfield SchoolHitchin Boys SchoolHitchin Girls SchoolKingshottKnights TemplarThe PriorySt ChristophersSt FrancisI am home schooledMy school is not listed here or I go to school outside of Hitchin or LetchworthI am not school aged and do not attend school
About How You Are Feeling And The Support You Require

Please complete this next section carefully and as honestly as you can. Supporting you to access the right service is very important to us. **If you are completing this on behalf of a young person, please ensure you have their consent before continuing.
Below are some questions about different parts of your life, including home, school / work, your mood, your physical and mental health and your friendships. Please tick the box that best describes your experience of each of these over the last 2 weeks.
How would you rate your overall happiness at home?*

Very unhappyUnhappyOkayHappyVery happy
How do you feel about going to school or work each day?*

Very unhappyUnhappyOkayHappyVery happy
How do you feel about your physical health?*

Very unhappyUnhappyOkayHappyVery happy
How do you feel about your mental health?*

Very unhappyUnhappyOkayHappyVery happy
How do you feel about your friendships?*

Very unhappyUnhappyOkayHappyVery happy
How is your overall mood?*

Very unhappyUnhappyOkayHappyVery happy
Please tell us in more detail about what you have been experiencing in particular and how you have been feeling recently, including any challenges you have had.*

0/8000
What are you hoping to achieve by working with GRIT? What is your goal?*

0/8000
Is there any additional information we need to know for you to access our services? e.g language, disability, access issues?

0/8000
What type of support do you feel you require? Don't worry if you are unsure, please tick the last box to receive our advice*

One to one support. I would like to talk to someone confidentially about the way I am feelingOne to one support. I don't feel comfortable in groups and would prefer to speak to someone on my ownGroup support. I would like to join a group with other young people that combines physical activity to understand why I feel the way you doI am unsure of what support / service I need and would like GRIT to advise or recommend
Thank you for telling us how you feel. We understand that sharing details like this is a big step, particularly if you have never accessed a service like this before.

We are here to help and support you every step of the way, and our team is dedicated to making sure you feel safe and understood throughout this process.

All we ask now is that you read the important notice below and let us know you are happy to proceed.
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 GRIT believes poses a risk to the client, a risk to other people, a risk to the safety and welfare of a young person, 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
Signature*

Clear
Should be Empty:

GRIT Referral Form

PLEASE NOTE: We are unable to deal with emergency enquires. If you need urgent advice, please contact your GP (Doctor) or the 111 Service.

Your Contact Details (Young Person)

Your Parent / Carer Details

Referrer Details

Emergency Contact

About You (Young Person)

About How You Are Feeling And The Support You Require