Young Persons Online Referral Form

Complete this form to make a referral or refer yourself to the Young Persons Service (provided by WithYou).

Family Worker Referral form

Family Worker Referral form

We Are WithYou for Family and Carers

We provide free and confidential support to family and carers around drugs and alcohol by offering a safe, non-judgemental and confidential space to talk. We work with people on their own goals, whether that’s staying safe and healthy, making a small change or stopping completely.





To view our full privacy policy please follow the link below

WithYou Privacy Policy 

 

Please confirm you have read and agree to our data protection policy
Name and contact number of parent/carer

Contact Details of Parent or Carer being referred

Referral for: (please tick the relevant box) * Please note 1:1 sessions are not available or families open to Child and Family Wellbeing or Children's Social Care.

Consent

Does the parent/carer know about this referral?
Has the parent/carer consented to this referral? Please ensure consent is gained prior to making the referral.
Contact details of the person you are referring

Contact Details of the person you are referring

Please enter a residential town
Does the person you are referring have a fixed address? *
Your details

Your details

Please use numbers only
Additional questions
Are Child Family Wellbeing Services or Children’s Social Care involved?
Please include: ● Risk ● Reason for referral ● Any other agency involvement; if yes, please add contact details