Low-intensity Wellbeing Referral Form

If you are worried about the safety of a child, please contact Access and Response on 01454 866000 Monday to Thursday 9.00 – 5.00, 4.30 on Friday, 01454 615165 out of hours and at weekends. If a child or young person is in immediate danger then please dial 999 and ask for police assistance.

Referrer’s Details

If self-referring, answer ’self’ in the boxes

Young person’s details

We ask for the contact details of the young person (if possible) so we can arrange a pre-assessment call to understand what they hope to achieve during their one to one support.

Please note, we do not offer support with all of the above and this is for information purposes only

I understand that by completing this form, the details I have provided above will be taken, saved and stored by Creative Youth Network for data protection reasons, namely to provide one to one support to young people. I have been advised that if I want to know more detail about how Creative Youth Network deal with my information, I can ask to see the full Privacy Notice for Young People, Parents and Carers May 2018.