South Gloucestershire - Wellbeing Referral Form

The information you enter into this form will be collected and stored by Creative Youth Network. Tick the tickbox below to confirm you understand.

I understand

If the young person is under 10 years old, it is necessary for a parent or carer to attend sessions too, and in some cases for the work to be entirely parent-led. Is the parent or carer willing to be involved in this way?

YesNo

Other details that might assist CYN with the appropriate allocation e.g. English as a second language, LDD, sensory impairment, known medical condition. *

Please enter details below if there are any other agencies working with the young person and/or the members of his/her family that we should know about. *

Which of the following locations is the young person able to travel to? (Please tick all that apply) *

HomeKingswood EstateSchoolSpace to meet one to one

Would this young person benefit from working with a wellbeing practitioner (Mild to moderate mental health needs):

Anxiety (general or social)Low mood/depression

Has the young person experienced any Adverse Childhood Experiences (ACEs)? Mark all that apply: *

Physical abuseSexual abuseEmotional abuseLiving with someone who abused drugs Living with someone who abused alcoholExposure to domestic violenceLiving with some who was incarceratedLiving with someone with serious mental illnessParental loss through divorce, death or abandonment

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.

South Gloucestershire - Wellbeing Referral Form

Referrer’s Details

Young person’s details