Niyyah Community Enterprise CIC Self-Referral & Enquiry Form

Niyyah Community Enterprise CIC Self-Referral & Enquiry Form

Niyyah Community Enterprise CIC Self-Referral & Enquiry Form
Welcome to Niyyah's Self-Referral & Enquiry Form.

If you or your child need support from Niyyah Community Enterprise CIC, please complete this form.

A member of the team will contact you within 3-5 working days.

If your query relates to a safeguarding concern, please tick the appropriate box below — safeguarding concerns are prioritised.
SECTION 1 — About You
Full Name:

First NameLast Name
ParentCarerResponsible AdultYoung Person (13+)Professional
If Professional, please specify your role:
Email Address:
example@example.com
Phone Number:
Format: (000) 000-0000.
PhoneEmailWhatsAppNo preference

SECTION 2 — About the Child/Young Person (if applicable)
Name of child/young person:
Age:
School:
YesNoNot sure
Youth Hub (Thursday)Warm Welcome SpaceHAF ProgrammeParent & Carer Drop-InOther

SECTION 4 — Tell Us About Your Enquiry
What would you like help with? Please describe your situation:
As much as you feel comfortable to share
Additional information we should know (optional):

I consent to Niyyah Community Enterprise CIC storing and processing my information to respond to this enquiry.I consent to being contacted about support, opportunities and services.I understand safeguarding concerns may need to be shared with statutory agencies in line with procedures.
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: