Service Referral Form

I am a...

Young person referring myself
Parent referring my child
Professional referring a young person

I am looking for

1-2-1 Counselling

Referrer's Details

Please complete this section telling us who is making the referral. You will be asked about the young person in the section below. We cannot accept the referral if this section is not completed.

First Name *

Last Name *

Job Title

Postcode *

Organisation

Email *

Phone

Mobile

Relationship with Young Person *

Consent *

I confirm that I have the consent of the young person named below to refer them to TeenTalk

Young Person's Details

Please complete the section below giving information about the young person you are referring. It is essential that you have the consent of the young person to refer them to us.

First Name *

Last Name *

Phone

Home Postcode *

Date of Birth *

Mobile

School/College

Gender

Other Gender

Preferred Pronoun

She/Her
He/His
They/Them

I have an existing diagnosis for

CAMHS *

I have not been referred to, or previously seen CAMHS
I have a referral to CAMHS but have not seen them
I was referred to CAMHS but they have recommended I contact TeenTalk
I have previously received support from CAMHS

Which location would you like to attend *

Melksham
Chippenham
Westbury
Remote (Via Microsoft Teams or Telephone_

Which location would you like to attend *

Melksham (The Canberra Centre)

The Legal Bit

In order to retain and use your contact details under GDPR regulations we have to ask your permission to contact you back. Please tick the relevant boxes below. Remember, if you don't say we can contact you using a method we can't do it!

What is the best telephone number to contact you on to arrange your appointments? *

Please enter the phone number that we should use to call you to arrange your appointments. This can be a parent/carer's telephone but when we first call we will need to speak to the young person to undertake an initial assessment over the phone. By entering your number here you are expressly giving us consent to call you for the purposes of arranging services from TeenTalk.

Which of the following methods are you happy for us to contact you on? *

Email
Home Phone
Mobile Phone
Text Message

Please be assured that we will never pass on your details to anyone else. They will only be used so that our Early Help and Support Team can contact you about your referral and any appointments for you to meet with us or to keep you informed about our services at 4Youth (South West)

IMPORTANT
By submitting this referral form you are consenting to TeenTalk/4Youth (South West) retaining and storing the information supplied as set out in our Privacy Policy. All information supplied is held in strict confidence and access to it is restricted only to those who require access in order to carry out their duties at 4Youth (South West).

Make a Referral

Service Referral Form

Referrer's Details

Young Person's Details

The Legal Bit