Referral

Do you give us consent to store and use your information in line with GDPR / Data Protection principles to provide the service you are requesting?

YesNo

Do you give us consent to contact you regarding special offers and FREE services when funding is in place?

YesNo

If you are making this referral for someone else please add your name and contact information below

Person / Organisation making the referral


Person paying for services


Contact information for Person paying for services


Referrer Phone


Referrer Email

Please complete the form below in regards to the person being referred

Full Name of person being referred

Please specify your Ethnicity?

Please specify your gender?

Please confirm your age? E.G 24

Date of birth

Phone Number

Email

Address line 1

Address line 2

Town/City

Postcode

Therapeutic / Counselling / Talking Services
Wellbeing Services
Youth / Young People Services
Mental Health Services / Advocacy / MH First Aid training
Suicide Prevention Training
Mens Health / Mens Groups
Projects
Other

If other please provide more details?

How would you like us to contact you? E.G. Phone, text, Email other

How did you become aware of the service?

Your General Practitioner (GP) details (Name, Contact, Address)

Do you have any other support in place? E.G. Social Worker, another organisation (If Yes, please provide more information)

Circumstances we should be aware of, E.G. Gang affiliation, NEET (Not in Employment, Education or Training)

If Yes, please provide more information. E.G. How long, any other issues

Tell us what support you think could help?

Have you ever used A Father's Child Services CIC services?

Has anyone related to you / affiliated with you used A Father's child Services CIC services?

Do you know anyone that works at A Father's child Services CIC?

How enthusiastic are you or the person you are referring with wanting to make change? 10 being most positive.
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Do you class your self as being affiliated with a gang?

Other please specify? E.G. Domestic Violence/Grooming? (Enter N/A if nothing applies)

Please describe what may be worrying you. (Enter N/A if nothing applies)

Have you been experiencing Low Moods? (E.G Please state if it's 2 weeks, more than a month, etc.)

Have you been given a clinical diagnosis by a GP or Specialist?

If Yes please specify.

Have you been experiencing thoughts of self harm or using self harming behaviours to cope

Have you been experience any suicidal thoughts / feelings or have plan in place?

If yes, could you please tell us more information about the suicidal throughs / feeling and or plan you have in place.

Worries around your relationship with Food

Have you spoken to anyone about how you are feeling? If yes please give us more information as to who.

What support if any do you already have in place? If Nothing in place advise N/A

Have you or anyone in your household suffered from Covid-19, Flu like symptoms, a temperature or been in contact with someone that has in the past 7 days?

If yes, have you tested positive for Covid-19 in the past 7 days?

Have you been in contact with someone who has had to self-isolate in the past 7 days?

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