Self referral form | Referral Form - Young People, Parents & Carers (referring 13+ year olds)

Referral Form - Young People, Parents & Carers (referring 13+ year olds)

* Indicates a required field

Who is making this referral? *

I am referring MYSELF to 42nd Street

First referral to 42nd Street?

Yes

Unknown

How did you hear about 42nd Street?

If Other, please state:

Characters remaining :

Do you need an interpreter?

Yes

Language needed:

Young Person's Information

Title

First Name *

Characters remaining :

Surname *

Characters remaining :

I am known as and my pronouns (e.g. he/him; she/her; they/them) are:

Characters remaining :

Date of Birth *

Gender Identity: *

Accommodation Type *

Gender identity not listed above:

Characters remaining :

My gender identity is different to the one I was assigned at birth *

Yes

Unknown

Prefer not to say

I identify as intersex

Yes

Do not know

Prefer not to say

Area of Residence:

My Address:

Address Line 1 *

Characters remaining :

Address Line 2

Characters remaining :

Address Line 3

Characters remaining :

Town/City *

Characters remaining :

Post Code
If Unknown enter ZZ99 3WZ
Homeless - no current address: ZZ99 3VZ *

Characters remaining :

Consent to post letters to this address

How Can We Get In Touch With You? (Young Person) Please tick at least one consent box

Telephone Number (Home)

Consent to call home telephone

Voicemail consent (Home)

Telephone Number (Mobile) *

Consent to call mobile telephone

Voicemail consent (Mobile)

SMS consent

Email address

Characters remaining :

Email consent

Access Needs

Primary Communication Preference

Primary Communication Preference Notes

Characters remaining :

Secondary Communication Preference

Secondary Communication Preference Notes

Characters remaining :

Accessibility Communication Support - Select main support required, if any

If more than one required, enter here:

Characters remaining :

Accessibility Contact Method - Select best method, if any

If more than one required, enter here:

Characters remaining :

Accessibility Communication Professional - Select main supporter, if any

If more than one required, enter here:

Characters remaining :

Accessibility Information Format - Select main format required, if any

If more than one required, enter here:

Characters remaining :

GP Details

Name of GP

Characters remaining :

Name of GP Surgery *

If GP Surgery not listed above enter here:

Name of GP Surgery

Characters remaining :

Address of Surgery (Including Postcode)

Characters remaining :

Phone number of Surgery

Email of Surgery

Characters remaining :

My School / College / University / Training / Employment:
(please select the most relevant option)

I am at School / College / University

Name of School / College / University:

If not listed above, name of school, college or university

Characters remaining :

In Training

Employed

I am a Parent / Carer who is referring a young person. My contact details are:

First Name of Parent / Carer

Characters remaining :

Surname of Parent / Carer

Characters remaining :

Address of Parent / Carer (including postcode)

Characters remaining :

How Can We Get In Touch With You?
(Parent/carer making a referral)

Primary telephone number

Consent to call primary telephone

Voicemail consent for primary telephone

SMS consent

Email address

Characters remaining :

Email consent

Appointment Preferences
* please see bottom of page for details

Appointment time:

Day

Evening

Either Day or Evening

You can access support in different ways - please select all options that you would be happy with:

Remote video (Microsoft Teams)

Online text-based (Messaging / Web chat)

Face to face

Telephone

Do you have a preference around the gender of your worker? This is not always possible to accommodate or you may wait longer for support. Please state:

Characters remaining :

Please tick if you need a community-based appointment

My Identity

Ethnicity: *

Sexuality: *

Sexual orientation not listed above:

Characters remaining :

Disability: *

If more than one disability, or the disability is not listed, please add these here:

Characters remaining :

Young carer for a parent/carer or family members: *

Yes

Prefer not to say

I am pregnant or have caring responsibilities for a child under 2 years old: *

Yes

Prefer not to say

Care Experience *

I would like to receive a confirmation of the referral to the email address I specified above. Please check the spam folders within your email if you do not receive a confirmation in your inbox.

Data Protection Policy and Confidentiality Policy

We let your referrer and your GP know that your referral has been accepted and also when you finish support at 42nd Street. We may also contact your GP during support if we are worried about your safety or wellbeing. We don’t share everything you tell us in sessions, just the information about our concerns. *

Appointment Preferences *Please be aware that preferences are not always available*
Last available appointment 6.00pm at our office base on Mon, Tues, Wed & Thurs; 4pm on Fridays

You will receive notification that your referral has been submitted. If you wish to keep a copy of the referral for your own records, please copy each page of the form before submitting.

We know this isn’t ideal. The development team at PCMIS are working hard to create download and print functionality within the form.

If you would like to know more about 42nd Street, our individual therapeutic support, group work, social action or creative programme, please visit our website www.42ndstreet.org.uk

Contact Telephone: 0161 228 7321

Contact Email: theteam@42ndstreet.org.uk