Group Work Referral Form

Thank you for showing your interest in potentially joining our Groupwork. We are looking forward to hearing from you!
Please note the following:
- This referral form is to be completed by young people aged 11 - 18 wishing to access our service.
- If you are a young person below the age of 13, you need your parent/carer's consent to complete this form.
- If you feel at risk of harm to yourselves or others, please contact your GP to discuss a safety plan as we are not able to provide emergency care. Please also note the crisis numbers on our website if needed.
- If you have any difficulties filling in this form or have any queries you would like to discuss, please get in touch with us by either calling 01392 410530 or emailing us at wellbeing@ymcaexeter.org.uk.
  
  All information given will be treated as strictly confidential.
Who is completing this referral form?:*

Child or Young PersonParent/Carer
For children aged 13 and under, we MUST have parental consent for a referral to be made. Please tick this box to confirm that you have obtained consent from a Parent/Carer.*

YesNoAged over 13
Please ensure a parent/carer for you has viewed and is happy with our Information Sharing Consent Form which can be found by clicking on image below.
Child or Young Person's Details
Name of Child or Young Person*

First NameLast Name
Preferred Name*
Child or Young Person's NHS Number*
If unknown, please state Unknown
Date of Birth*

DayMonthYear
Date
Describe Gender*
Contact Number*
Please enter a valid phone number.
Who does the above phone belong to?*
Is there a good time to contact you? If so, please give days and times:*
Can we leave a voicemail on this phone?*

YesNo
Email*
How do you prefer to be contacted?*
We will do our best to reach you using the preferred contact details you provided. If we are not able to reach you using your preferred contact details, we may try other ways to get in touch. Please double-check that your information is accurate and that you are happy for us to contact you via the details provided.
Address*

Street Address

Street Address Line 2

CityRegion

Post Code
Accommodation Status (Please tick the relevant option):*

Parent or carer owns/rents the houseTemporary accommodationSofa Surfer
If an alternative answer to above question, please specify:*
Please type N/A if this question is not applicable.
Ethnicity:
(Please tick appropriate box)*

White and Black CaribbeanWhite and Black AfricanWhite and AsianWhite BritishWhite IrishWhite otherIndianPakistaniBangladeshiCaribbeanAfricanOther
If "Other" to any of the above ethnic groups, please specify:*
Please type N/A if "Other" option was not used.
Prefer not to say:
Long Term Condition Status:(Please tick the relevant option)*

AsthmaCancerChronic painDementiaDiabetesEpilepsyHeart FailureMedically Unexplained ConditionsNo Long-Term Health Conditions
Child Protection Plan: (Please tick the relevant option)*

Has never been subject to a Child Protection PlanHas previously been subject to a Child Protection PlanIs currently subject to a Child Protection Plan
Are you a Looked After Child? (In public care, living with foster carers, in residential homes or with other relatives)*

YesNoPrefer not to say
Who is your Education provider?*
(E.g., School name, College name, Apprenticeship)
School Year:*
GP Practice:*
(If unknown, please state unknown)
Who is your registered GP?*
(If unknown, please state unknown)
Do you have a disability?*

YesNoPrefer not to say
If yes, please specify *
If no disability, please write N/A.
Do you require constant supervision or care due to a disability?*

YesNo
Are you a Young Carer?*

YesNo
If yes, please specify who you are caring for:
Do you feel at risk to yourself?*

YesNo
Do you feel at risk to others?*

YesNo
Do you feel at risk from others?*

YesNo
If you have answered "Yes" to any of the above questions regarding feeling at risk, please give details:*
Please type N/A if you responded "No".
Do you consent for your data to be kept confidentially on YMCA Exeter’s record? PLEASE NOTE: without this consent to store your data we are unable to provide support.*

YesNo
REASON FOR REFERRAL

Please provide as much information as possible to the following questions.
Mind and Mood is a therapeutic group for the management of symptoms related to anxiety and depression.
Which of the following do you experience?*

AnxietyDepressionBothNot Applicable
What are the main symptoms experienced?*
How long have you been experiencing these symptoms?*
How often do these symptoms occur?*
What is the impact of these symptoms on your day-to-day life?*
Please let us know if any other professionals (e.g. Social Worker or GP) ARE working with your family currently (and if so, what support are they providing)?*
Please type NO if this question is not applicable.
Please let us know if any other professionals HAVE worked with your family within the last year (and if so, what support they provided, and when was this)? *
Please type NO if this question is not applicable.
Please give additional information you feel would be helpful for us to know when processing your referral:*
NEXT OF KIN DETAILS

Should this form be completed by the young person themself, we need their Next of Kin details for safeguarding purposes.
Name of Next of Kin*

First NameLast Name
Relationship to Child/Young Person:*
Email*
Contact Number*
Please enter a valid phone number.
Today's date:

DayMonthYear
Date
Is there any information that you would prefer to not be shared or any person/organisation they would not want this information shared with?*
Signature:

Upload electronic signature if you have one.
Cancelof
If you do not have an e-signature, please type your name here:
By submitting this form, you confirm that you have read and consented to our Attendance Agreement on our website (found in the "Refer to CWP Services" section on our website).*

I confirm
Should be Empty:

Thank you for showing your interest in potentially joining our Groupwork. We are looking forward to hearing from you!

Child or Young Person's Details

Ethnicity:

REASON FOR REFERRAL

NEXT OF KIN DETAILS