Self referral form | 42nd Street Referral Form - Professionals

42nd Street Referral Form - Professionals

Professionals referring young people 13+ years (11+ for school referrals only)

* Indicates a required field

First referral to 42nd Street? *

Yes

Unknown

Interpreter required? *

Yes

Language:

Young Person's Information

Title

First Name *

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Surname *

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The young person is known as, and their pronouns (e.g. he/him; she/her; they/them) are:

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Date of Birth *

Gender Identity:

Gender identity not listed above:

Characters remaining :

Gender identity of Young Person is different to the one assigned at birth

Yes

Does the young person identify as intersex?

Yes

Do not know

Prefer not to say

Area of Residence:

Address of Young Person:

Address Line 1 *

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Address Line 2

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Address Line 3

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Town/City *

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

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Consent to post letters to this address

Contact Details of Young Person
and Communication Consent

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

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Email consent

Access Needs

Primary Communication Preference

Primary Communication Preference Notes

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Secondary Communication Preference

Secondary Communication Preference Notes

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GP Details

Name of GP

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Name of GP Surgery *

If GP Surgery not listed above enter here:

Name of GP Surgery

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Address of Surgery

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Post Code of Surgery

Phone number of Surgery

Email of Surgery

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Is this a GP referral?

Education / Training / Employment:
(please select the most relevant option)

Is this a referral from a school part of the Thrive in Education Programme?

Is this a referral from a school/college part of the Mental Health In Education programme?

Is this referral from a school/college which has an independent contract with 42nd Street?

Is this referral from the Princes Trust referral pathway?

Is this referral for the Pathfinder pathway?

Name of School / College / University:

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

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In Training

Employed

Referrer Details

Name of Referrer *

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Referrer Job Title/Role

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Name of Referring Organisation *

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Referrer Address *

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Referrer Post code

Referrer Phone Number

Referrer Email

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Referrer Type *

Please state name (if applicable)

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Appointment Preferences
* please see bottom of page for details

Appointment time:

Day

Evening

Either

You can access support in different ways - please tick 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:

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Please tick if the young person needs a community-based appointment

Identity information of Young Person

Ethnicity: *

Sexuality: *

Sexual orientation not listed above:

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Disability: *

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

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

Yes

Prefer not to say

The young person is pregnant or has 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 the referrer and the young person's GP know that the referral has been accepted and also when they finish support at 42nd Street. We may also contact their GP during support if we are worried about their safety or wellbeing. We don’t share everything they tell us in sessions, just the information about our concerns. *

The confirmation email will only be sent to the young person’s email address

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