Shaping My Future Referral Form

Shaping My Future

Is a project designed by and for young people who are aged 16–24 in Inverclyde living with long-term mental or physical health conditions, learning difficulties, or disabilities. The project supports participants in taking control of and improving their health and well-being, self-managing their conditions, and gaining independence.

The 12-week-programme includes:

🍳 Cooking Sessions – Learn to prepare healthy, budget-friendly meals you can easily recreate at home.
🌟 Workshops – Covering topics like understanding your condition, living independently, growth mindset, food and health, stress management, personal finance, navigating healthcare systems, and employability.
🎯 1:1 Solution-Focused Coaching – Tailored support to help set and achieve your goals.
👥 Peer Support Groups – Build connections and friendships in a relaxed and supportive environment.
✨ Specialised Support – Expert health, wellbeing, and life skills guidance.
🏆 Leadership Training – Gain skills to lead and support others.

This is a chance for young people to develop practical skills, grow in confidence, and create a positive path for their future.

👉 If this sounds like you, fill out our referral form below to register your interest.

If you know or work with a young person who might benefit, please help and encourage them to refer or pass the referral form on.
Young Person's Personal Details
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Mobile Number*
Email Address*
D.O.B*

DayMonthYear
Date
Gender*

MaleFemalePrefer to self describe
National Insurance Number *
What is your ethnic group:

White ScottishWhite OtherAsianAsian ScottishAsian BritishBlackCaribbeanMixed or Multiple BackgroundsOther Ethnic Background
What is your marital status?

SingleLiving with PartnerMarriedWidowedSeparated/ DivorcedPrefer not to say
How did you hear about Stepwell's 'Shaping my Future'?*

Stepwell Social Media PostInverclydeNOWWork Coach at the Job Centre (DWP)Friend/Family MemberSchool or NurseryTesco Pop UpPG Health Centre Pop UpGreenock Health Centre Pop UpStepwell PostcardLocal Organisation (i.e HomeStart, Barnardos, Fitzgerald Centre)Other
Referral Details (if referring for a young person)
Relationship to Young Person*
Organisation Name (if applicable)
Contact Details

First NameLast Name
Mobile Number
Email Address
Disabilities and Long-term Conditions
Please tell us which of the following applies (Please tick all that apply):

I have a Physical Health Condition (e.g. Osteoporosis, Irritable Bowl Syndrome (IBS), Asthma, Epilepsy, COPD, Fibromyalgia, etc.)I have a Mental Health Condition (e.g. Depression, Anxiety, Bipolar Disorder, OCD, PTSD, etc.)I have a Learning Difficulty/Disability (e.g. Asperger's Syndrome, Autism Spectrum Disorder, Hyperactivity Disorder (ADHD), Dyslexia, etc.)I do not have a disability and/or long-term conditionOther Health Condition (please state)
Physical Health

Do you have any of the following Coronary/Heart Conditions?

(Please select all that apply)
*

I do not have a Coronary/Heart ConditionAnginaArrhythmiaHypertension (High Blood Pressure)Hypotension (Low Blood Pressure)Coronary Artery DiseaseMyocardial Infarction (Heart Attack)Pulmonary EmbolismStroke (Cerebrovascular Accident)
Do you have any of the following Respiratory Conditions?

(Please select all that apply)
*

I do not have a Respiratory ConditionAsthmaCOPDLong COVIDPneumoniaPulmonary Fibrosis
Do you have any of the following Musculoskeletal Conditions?

(Please select all that apply)
*

I do not have a Musculoskeletal ConditionSciaticaSpondylosisArthiritisRheumatoid ArthritisOsteoporosisHerniated DiscGoutRepetitive Strain InjuryPlantar Fasciitis
Do you have any of the following Neurological Conditions?

(Please select all that apply)
*

I do not have a Neurological ConditionEpilepsyParkinson'sVertigoCerebral PalsyNarcolepsyBrain Injury Related ConditionSevere MigrainesInsomniaMultiple Sclerosis (MS)
Do you have any of the following Impairments?

(Please select all that apply)
*

I do not have a Physical ImpairmentVisualHearingSpeech
Do you have any other Conditions?

(Please select all that apply)
*

I do not have any other conditionsThyroid ProblemsDiabetesCoeliac DiseaseIrritable Bowl Syndrome (IBS)Raynaud's DiseaseChronic Pain
Mental Health

Do you have any of the following Mental Health Conditions?

(Please select all that apply)
*

I do not have a Mental Health ConditionAgoraphobiaClinical DepressionMild DepressionBipolar DisorderSeasonal Affective Disorder (SAD)Chronic StressChronic AnxietySocial Anxiety DisorderSevere Panic AttacksObsessive Compulsive Disorder (OCD)Post Traumatic Stress Disorder (PTSD)Low MoodEating Disorder (i.e Anorexia /Bulimia)SchizophreniaBrain Injury Related ConditionPostpartum DepressionBorderline Personality Disorder
Learning Difficulties and/or Disabilities

Do you have any of the following Learning Difficulties and/or Disabilities?

(Please select all that apply)
*

I do not have a Learning Difficulty/DisabilitiesAutismAsperger's SyndromeDyspraxiaDyslexiaAttention Deficit Disorder (ADD)Down's SyndromeAttention Deficit Hyperactivity Disorder (ADHD)Brain Injury Learning Difficulty
Declaration
Please confirm the following:*

I live in InverclydeI am aged between 16-24I have a disability and/or long-term conditionAll the information in this registration is accurate and true.Stepwell can record* and use my personal information to keep in touch as well as share collated data with funders.
Please sign your name (The Young Person) in the box below to confirm registration:*
* In line with current GDPR legislation please tick the box to confirm you are happy for us to collect, store, use and dispose of personal data/ your personal information. Please note we abide by the date protection principles set out in the General Data Protection Regulation and the Data Protection Act 2018. Stepwell's privacy notice can be provided on request.
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