Young Person Referral

If you would like to refer yourself or someone else, please complete the form below. Please note you must have the young person's consent before you refer them to our service. We will contact the person who submitted the form to confirm the referral.

Are you a professional referring a young person?

Healthcare professionals, social workers, colleges and other referring professionals can use this form directly. Please select the appropriate option under "Referred by" and provide your name in the "Name of Referring Professional" field.

For general enquiries, please use our Contact Form.

What happens after you send this

Your referral goes straight to our team — it is not published anywhere.
We aim to reply within 72 hours during office hours (Mon–Fri, 9am–5pm).
We will contact whoever submitted this form first, to confirm the referral.

We are not a crisis service. If you need help right now, please see our urgent support page or call 999 in an emergency.

Fields marked with a label are all needed unless the label says optional.

Referral Information

Referred by

Name of Referring Professional

Only needed if you are a professional making this referral. Leave blank otherwise.

Young Person's Details

First Name

Surname

Date of Birth

We support young people aged 11 to 25.

Contact Information

Address

Optional.

Post Code

School or Workplace

Optional.

Email Address

Mobile Number

Medical Information

GP Surgery Details

The name and address of the young person's GP surgery.

Reason for Referral

Brief Description

A short summary is fine — we will ask for more when we get in touch.

250 characters remaining