TS Referral

I confirm that I am the young person and I am making a referral for myself*

YesNo

Referral Date*

Date

Name*

First NameLast Name

Preferred name (if different to the one above)

Date of Birth*

Date

Pronouns

She/HerHe/HimThey/ThemOther

Ethnicity (e.g., White British, Black Caribbean)

Address*

Street Address

Street Address Line 2

CityCounty

Post Code

Your Contact Details*

Do you have any medical or dietary needs*

Do you feel you have any of the following? (select all that apply)

Parent/Carer Contact Details (If known)

Year group *

Attendance %

Name of School*

Are you currently in an education, employment or training

Are you at risk of losing your place within the education, employment or training

Do you consider yourself to have other significant concerns you would like support with

Are you currently being supported by any other professionals or services? (e.g. CAMHS, Social Care, YOS, Project 28, Mentoring Plus, Southside). Can you share the details of the other professionals you are working with

What outcomes are you hoping this will help you with? (Please tick all that apply)

Improved emotional resilienceBetter mental healthGreater independence, confidence, and self-esteemMaking healthier choicesEngaged in education, employment or training, with goals for the futureFeeling safe and protectedInvolved in your local community

Young person’s comments – What support would you like from us?

What’s the best way for us to get in touch with you?

Text or call meEmail me

Thinking About Getting Support?

We’re here to help.

If you're finding it hard to stay in education, training, or get into work – or you're not currently doing any of those – we might be able to support you.

We offer one-to-one help and practical support for young people who:

Are struggling to stay in school, college, or training
Aren’t currently in education, work or training (this is called being NEET)
Aren’t getting support from other services

Our goal is to help you overcome challenges, feel more confident, and build a more positive future.

You can get this support if you:

Live in Bath and North East Somerset
Are aged 13–19, or up to 25 if you have additional needs, special educational needs or a disability

What We Can Help With

We’ll work with you to:

Find the right path into education, training, or work
Build confidence and resilience
Improve your wellbeing and mental health
Set goals and take positive steps in your life and community

We also keep track of how young people in the area are doing in terms of education and employment, as part of our responsibility to the local council.

Do I Need Consent?

Yes, because you’re in charge of your journey.

If you're 14 or over, you need to understand what you're signing up for and agree to the support
If you're under 14, we’ll also need your parent or carer to agree

The support is completely voluntary, so it’s up to you if you want to take part.

If you’re not sure whether this service is right for you, feel free to get in touch for a chat.

Email us at targeted.referrals@ycsw.org.uk or call 01225 396980 and leave your name and number – someone from our team will get back to you.

How We Use Your Information

We take your privacy seriously.

We’ll use the information you give us to make sure you get the right kind of support. Your details will be kept safe and will only be shared with your permission – unless there’s a legal or safeguarding reason.

If you want to know more about how we handle your data:

Call us on 01225 235659 or read our full privacy notice at www.youthconnectsouthwest.org.uk/policies

Signature - (Type your name)

Please verify that you are human*

Face to Face Support Referral Form

Your Details

Current Education Setting

Reasons for Referral

Thinking About Getting Support?

What We Can Help With

Do I Need Consent?

How We Use Your Information