YMCA and Community Group Work Referral Form

Thank you for showing your interest in potentially joining our Groupwork. We are looking forward to hearing from you!
Please note the following:
- This referral form is to be completed by people aged 18 - 25 wishing to access our service.
- If you feel at risk of harm to yourselves or others, please contact your GP to discuss a safety plan as we are not able to provide emergency care. Please also note the crisis numbers on our website if needed.
- If you have any difficulties filling in this form or have any queries you would like to discuss, please get in touch with us by either calling 01392 410530 or emailing us at wellbeing@ymcaexeter.org.uk or alternatively you can contact your Support Worker.
  
  All information given will be treated as strictly confidential.
Please ensure you have viewed and are happy with our Information Sharing Consent Form which can be found by clicking on image below.
Personal Details
Name *

First NameLast Name
Preferred Name*
NHS Number*
If unknown, please state Unknown
Date of Birth*

DayMonthYear
Date
Gender*
Employment Status*

Paid Work: Full TimePaid Work: Part TimeSelf EmployedFull time educationOut of work, registered unemployedOut of work, unregistered unemployedPermanently sick or disabledNot working for domestic reasonRetiredOther
If ticked "other" for employment status, please elaborate*
Please type N/A if this question is not applicable.
Contact Number*
Please enter a valid phone number.
Who does the above phone belong to?*
Can we leave a voicemail on this phone?*

YesNo
Is there a good time to contact you? If so, please give days and times:*
Email*
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.
Address*

Street Address

Street Address Line 2

CityRegion

Post Code
Accommodation Status (Please tick the relevant option):*

Owns/rents the houseTemporary accommodationSofa SurferSupported HousingYMCA Exeter Stage 1 - 4Other
If you ticked "Other" to above question, please specify:*
Please type N/A if this question is not applicable.
Any criminal convictions, please specify*
Please type N/A if this question is not applicable.
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:
Long Term Condition Status:(Please tick the relevant option)*

AsthmaCancerChronic painDementiaDiabetesEpilepsyHeart FailureMedically Unexplained ConditionsNo Long-Term Health Conditions
Who is your Education provider (if applicable)?*
(E.g., School name, College name, Apprenticeship)
GP Practice:*
(If unknown, please state unknown)
Who is your registered GP?*
(If unknown, please state unknown)
Do you have a disability?*

YesNoPrefer not to say
If yes, please specify *
If no disability, please write N/A.
Do you require constant supervision or care due to a disability?*

YesNo
Do you have any caring responsibilities?*

YesNo
If yes, please specify :
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".
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.
Do you consent for your data to be kept confidentially on YMCA Exeter’s record? PLEASE NOTE: without this consent to store your data we are unable to provide support.*

YesNo
REASON FOR REFERRAL

* Please provide as much information as possible to the following questions.
Which of the following do you experience?*

AngerAnxietyDepressionBothNot Applicable
What are the main symptoms experienced?*
Please give additional information you feel would be helpful for us to know when processing your referral:*
NEXT OF KIN DETAILS

Should this form be completed by the young person themself, we need their Next of Kin details for safeguarding purposes.
Name of Next of Kin*

First NameLast Name
Relationship you:*
Email*
Contact Number*
Please enter a valid phone number.
Today's date:

DayMonthYear
Date
Is there any information that you would prefer to not be shared or any person/organisation they would not want this information shared with?*
Signature:

Upload electronic signature if you have one.
Cancelof
If you do not have an e-signature, please type your name here:
By submitting this form, you confirm that you have read and consented to our Attendance Agreement on our website (found in the "Refer to CWP Services" section on our website).*

I confirm
Should be Empty:

Thank you for showing your interest in potentially joining our Groupwork. We are looking forward to hearing from you!

Personal Details

Ethnicity:

REASON FOR REFERRAL

NEXT OF KIN DETAILS