• Please note the following:

      This self-referral form is to be completed only by young people aged 13 - 18 wishing to access our service.  (Please note: this referral must be completed by the young person themselves, not parents/carers.)

    • If you are a young person below the age of 13, please ask your parent/carer to support you by completing a parent referral form for you on your behalf, which can be found on our website.  If you have any queries/problems with this, please get in touch with us by either calling 01392 410530 or emailing us at wellbeing@ymcaexeter.org.uk.

  • If you require any additional assistance with completing the referral form, please contact us at 01392 410530 or email us at wellbeing@ymcaexeter.org.uk.

  • Date of Birth *
     - -
  • Format: 00000 000 000.
  • Can we leave a voicemail on your phone?*
  • Accommodation Status: (Please tick the relevant option)*

  • Ethnicity:

  • (Please tick appropriate box)*
  • Do you have a disability?*
  • Rows
  • Do you feel at risk to yourself?*
  • Do you feel at risk to others?*
  • Do you feel at risk from others?*
  • Our Wellbeing Practitioners also offer evidence-based Low Intensity CBT group sessions. Please look at our website for more information on Groupwork. Would you like to be considered for Groupwork?*
  • Have you been referred to this form by a professional?*
  • How did you find out about our service?*

  • Do you consent for your data to be stored, as per the terms on our website (Wellbeing Practitioner Information Sharing Consent Form - YMCA Exeter)?

  • *

  • By submitting this form, you confirm that you have read and consented to our Attendance Agreement on our website.

  • Should be Empty: