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YMCA Exeter Children and Young People's Wellbeing Service - Self Referral Form
Please note - this form is to be completed only by young people (under 18) wishing to access our service. If you are a parent referring on behalf of your child, please complete the parent referral form on our website instead.
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Describe Gender
Pronouns
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact number
Can we leave a voicemail on your phone?
Yes
No
Email
example@example.com
How do you prefer to be contacted?
Please Select
Phone
Email
Is there a good time to contact you? If so, please give days and times:
Who is your GP? (Name and Surgery)
Do you have a disability? If yes, please state below:
Please put a tick in the box that shows how often each of these things happens to you. There are no right or wrong answers
*
Never
Sometimes
Often
Always
I worry about things
I feel sad or empty
Nothing is much fun anymore
I feel worried when I think someone is angry with me
I worry about being away from my parents
I get bothered by bad or silly thoughts or pictures in my mind
I suddenly feel as if I can't breathe when there is no reason for this
I have to keep checking that I have done things right (like the switch is off, or the door is locked)
I have trouble going to school in the mornings because I feel nervous or afraid
I worry I might look foolish
I worry that bad things will happen to me
When I have a problem, I feel shaky
I have to think of special thoughts (like numbers or words) to stop bad things from happening
I am afraid of being in crowded places (like shopping centers, the movies, buses, busy playgrounds)
My heart suddenly starts to beat too quickly for no reason
Out of the above statements, what is most difficult for you at the moment?
How often is this feeling difficult? When and where do you find this most difficult?
What areas of your life does this impact?
What would you like to change/be different?
What kind of support do you think would be most helpful for you?
Do you feel at risk to yourself?
Yes
No
Do you feel at risk to others?
Yes
No
Do you feel at risk from others?
Yes
No
If you have answered yes to any of the above, please give details:
Our Wellbeing Practitioners also offer ‘GroupTherapy’. Please tick if you do not wish to be considered for group sessions.’
I do not wish to be considered for group sessions
Have you been referred to this form by a professional? If so, please give details of who:
Are you currently being supported/ have you been supported in the last year by a professional e.g. Social Worker or GP?
Do you consent for your data to be stored, as per the terms on our website?
Yes
No
Submit
Should be Empty: