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

We Are With You

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 to understand how your personal data will be used. *

Name and contact number of parent/carer

Details of referred

Details of Parent or Carer being referred

Name of parent/carer being referred

Date Of Birth *

Contact details of the person you are referring

Town or city *

Does the person you are referring have a fixed address? *

Yes

Address line 1 *

Address line 2

Postcode *

Phone number *

Email address

Ethicity

Are there any other agencies involved, i.e. Early Help/GP/Mental health?

Your details

Relationship to Young Person/ Adult *

Referrer full name *

Referrer email

Contact number

Date of referral *

Does the parent/carer know about this referral?

Yes

Has the parent/carer consented to this referral?

Yes

Additional questions

Additional Questions

Are Child Family Wellbeing Services or Children’s Social Care involved?

Details *