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

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