With Youth Online - WithYouth

With Youth Referral Form

Please complete this form if you would like to access our services and we will contact you to discuss next steps. Please provide as much information as possible.

Your Details

Name *

First

Last

Preferred pronoun

Main Phone

Mobile

Email *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Please complete this section carefully. Supporting you to access the right services is very important to us but it isn't always easy to make contact, so listing as many contact options as possible will help us to help you more quickly.

Contact method

How would you like us to contact you?

Home phone
Mobile
Email

Is it OK for us to leave a message?

Yes
No

What time would you prefer us to contact you? (Between 2pm-10pm)

GP Details

GP Surgery *

School Details

Are you currently in education? *

Yes in school/college
Yes in home schooling
No

Name of school (if applicable)

Emergency Contact Information

Please confirm that you have the consent of the person for Herts Mind Network to contact in an emergency by ticking the checkbox below

My emergency contact has given their consent

Name

Contact number

Relationship to you

Further information

What type of support would you like to access or like more information about?

Please provide some information about your current situation, what support you are looking for and how you would like to access that? *

Are there any other agencies involved in your support at present?

Is there any additional information we need to know to make it easier for you to access our services? e.g. language, disability, access to digital devices? *

How did you hear about us? *

Other - How did you hear about us?

Details of referrer

(if completing the form on behalf of someone else)

Name of referrer

Email

Organisation

Tel number

The child/ young person has given verbal and/or written consent for me to make this referral

Yes
No

Equal Opportunities and Disability Monitoring

Age Group of child/ young person *

5-9
10-14
15-19
20-25

Gender *

Other gender description (please specify)

Sexual orientation *

Other sexual orientation description

Religion/ faith

Other - please specifiy

Ethnicity *

Do you have caring responsibilities?

Carer of a child (under 18)
Carer of adult family member
Carer of disabled child/ children
None

Data Protection and Confidentiality

Hertfordshire Mind Network adheres to the Data Protection Act 2018’s principles of good information handling and the EU General Data Protection Regulation 2018.

Please indicate below if you consent to us collecting, recording and processing your personal data for the purpose of providing you with support and to ensure your health, safety and wellbeing. We will use your information appropriately and in line with our Privacy Policy which you can see here: Privacy Policy

Your details will not be shared with anyone else without your consent. If you have any concerns or questions about how your personal data is collected and used, please ring us on 0208 189 8400 or email us at [email protected]. Please note that without your consent, you will not be able to submit this form and access Hertfordshire Mind Network’s services.

Where information is given in confidence that Hertfordshire Mind Network believes poses a risk to the client, a risk to other people, a risk to the safety and welfare of a child, or is against the law, we reserve the right to disclose that information to a relevant third party.

Do you consent to us collecting, recording and processing your personal data for the purpose of providing you with support and to ensure your health, safety and wellbeing? *

Yes
No

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