Wellbeing support - Referral form
We offer 1 to 1 wellbeing support for 16-19 year olds experiencing mild to moderate mental health issues. For young people under 16 or for young people with more complex needs, such as education, employment, housing and challenging behaviour, please go to Targeted Support.
Name
*
First Name
Last Name
Preferred pronouns
Age
*
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
It's okay to contact me via:
*
Phonecall
Text
Letter
Email
Current education / employment – Sixth form / College / NEET
Tell us a bit about what’s going on for you right now and how it is impacting you?
*
Do you have any other current support (e.g. CAMHS, school counsellor, Off the Record), or coping mechanisms that help you?
What are your hopes for this support?
Anything else that would be helpful for us to know?
Submit
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