Young Persons Online Referral Form

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

Kent Young Persons Online referral form

Kent Young Persons Referral form

Online referral form

We Are WithYou for Young People

We provide free and confidential support to young people 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.





This service is for you if:


  • -You are under 18

  • -You are aged 18-24 and you are not dependent on alcohol, opiates or pregnant (if this applies to you, please refer to adult services)

  • -You are living in Kent

  • -You would like to make some changes around your drug or alcohol use.

To view our full privacy policy please follow the link below

WithYou Privacy Policy 

 

Who is making the referral? *



Is the person you are referring *


Are you *


Your personal details

Your personal details

DD/MM/YYYY
Sex (at birth) * Help text




Gender identify *






(Parental consent is not essential for the referral)
Name and contact number of parent/guardian

Name and contact number of parent/guardian

Please use numbers only
Personal details of the person you are referring

Personal details of the person you are referring

DD/MM/YYYY
Sex (at birth) * What are their preferred gender pronouns?




Gender identify *






Contact details

Contact details

Do you have a fixed address? * Do you have a fixed address?


If yes, please add contact details.
Contact details of the person you are referring

Contact details of the person you are referring

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


If yes, please add contact details.
Substance use

Instructions


  • Ask the Young Person about every box in every section

  • When asking about substance use, tick if the YP has current use (in the last three months) AND if there is any past use. Please tick all appropriate boxes.

  • For every substance you have ticked, on the next page you will be prompted to provide additional information

  • Each substance description can be viewed by hovering over the checkboxes

Alcohol A drink which is a central nervous depressant and can make people feel more relaxed and euphoric, but also increases risk-taking behaviour and aggression.


Amphetamine A powder which is most commonly snorted. It is a stimulant which makes people feel more energetic and confident but can also cause restlessness, aggression and paranoia. Effects can last 4-8 hours.


Cannabis This may be smoked, vaped, or eaten which can change the length of the effects. People may feel happy, calm and more thoughtful but also more anxious and withdrawn.


Crack A smokable form of cocaine made by further ‘cooking’ it to make crystals. This produces a drug with quicker onset but shorter lasting effects than powder cocaine.


Cocaine A powder which is most commonly snorted. It is a short acting stimulant which may make people feel more alert and happy but also over-confident which increases risks. Effects last around 30 minutes.


Synthetic Cannabinoids Unlike cannabis, these are made in a laboratory to act on the same parts of the brain but can be much stronger. Their effects can be different and synthetic cannabinoids are generally more harmful. ‘Spice’ is widely used to mean any and all synthetic cannabinoids.


Ecstasy or MDMA Ecstasy usually refers to a pill pressed in a distinctive shape and MDMA to a crystalline powder, but both contain MDMA. It can make you feel more social and connected but people may also feel anxious during or after the experience. Effects can last 3-6 hours.


Heroin A fine brown powder that can be smoked or injected. It is a depressant which can create feelings of relaxation but also nausea and vomiting. At higher doses there are risks of slowed breathing and heart rate.


LSD These are psychedelic drugs that are taken orally and which alter your senses and thinking. ‘Trips’ can vary from person to person but may involve clearer sounding music, more vivid colours, altered perceptions of time and space, and sensations of spirituality and connectedness. LSD effects can last 6-12 hours and magic mushrooms effects can last 4-6 hours.


Benzodiazepines A group of tranquiliser drugs, commonly found as round pills which are swallowed. However it can be difficult to determine which are real and which are counterfeits. Generally they cause drowsiness, calmness and warmth but also blackouts and short-term memory loss which increases vulnerability for users.


Solvents/gas/glue/aerosols These are volatile substances such as butane (e.g. aerosols), petrol, and acetone, which are purposefully inhaled to get high. This can kill instantly.


Ketamine A powder which is most commonly snorted. The effects depend a lot on the dose, but generally low doses can bring energy or relaxation, and higher doses can be more ‘trippy’ with out of body experiences (known as a k hole).


New Psychoactive Substance (NPS) These are drugs designed to replicate the effects of other substances, previously known as ‘legal highs’, therefore effects vary from drug to drug.


Mephedrone A powder which is most commonly snorted or swallowed. It is a stimulant which can give more energy and talkativeness but also can cause a fast heart rate, anxiety, and headaches. It is sometimes said to be like MDMA but is more stimulant-like in its effects.


Nitrous Oxide A colourless gas often inhaled from a balloon (hence why it is sometimes known as ‘balloons’). Effects are very short lived but can cause euphoria and relaxation, but also light-headedness and confusion.


Performance or Image Enhancing Drugs These are drugs used to improve physical appearance and sporting performance, the most well known being anabolic steroids but includes a wide variety of different drugs with different effects and harms. Many of these drugs being sold in gyms are counterfeits or not designed for humans, which increases the risk.


Any other (e.g mystery pills or powders, misuse of prescribed medication)


Substance use

Instructions


  • When answering about drugs and alcohol, please tick if you are currently using and if you have used them in the past

  • For every drug you have ticked, on the next page you will be asked to give us some extra information

Alcohol. A drink which is a central nervous depressant and can make people feel more relaxed and euphoric, but also increases risk-taking behaviour and aggression.


Amphetamine. A powder which is most commonly snorted. It is a stimulant which makes people feel more energetic and confident but can also cause restlessness, aggression and paranoia. Effects can last 4-8 hours.


Cannabis. This may be smoked, vaped, or eaten which can change the length of the effects. People may feel happy, calm and more thoughtful but also more anxious and withdrawn.


Crack. A smokable form of cocaine made by further ‘cooking’ it to make crystals. This produces a drug with quicker onset but shorter lasting effects than powder cocaine.


Cocaine. A powder which is most commonly snorted. It is a short acting stimulant which may make people feel more alert and happy but also over-confident which increases risks. Effects last around 30 minutes.


Synthetic Cannabinoids. Unlike cannabis, these are made in a laboratory to act on the same parts of the brain but can be much stronger. Their effects can be different and synthetic cannabinoids are generally more harmful. ‘Spice’ is widely used to mean any and all synthetic cannabinoids.


Ecstasy or MDMA. Ecstasy usually refers to a pill pressed in a distinctive shape and MDMA to a crystalline powder, but both contain MDMA. It can make you feel more social and connected but people may also feel anxious during or after the experience. Effects can last 3-6 hours.


Heroin. A fine brown powder that can be smoked or injected. It is a depressant which can create feelings of relaxation but also nausea and vomiting. At higher doses there are risks of slowed breathing and heart rate.


LSD. These are psychedelic drugs that are taken orally and which alter your senses and thinking. ‘Trips’ can vary from person to person but may involve clearer sounding music, more vivid colours, altered perceptions of time and space, and sensations of spirituality and connectedness. LSD effects can last 6-12 hours and magic mushrooms effects can last 4-6 hours.


Benzodiazepines. A group of tranquilliser drugs, commonly found as round pills which are swallowed. However it can be difficult to determine which are real and which are counterfeits. Generally they cause drowsiness, calmness and warmth but also blackouts and short-term memory loss which increases vulnerability for users.


Solvents/gas/glue/aerosols. These are volatile substances such as butane (e.g. aerosols), petrol, and acetone, which are purposefully inhaled to get high. This can kill instantly.


Ketamine. A powder which is most commonly snorted. The effects depend a lot on the dose, but generally low doses can bring energy or relaxation, and higher doses can be more ‘trippy’ with out of body experiences (known as a k hole).


New Psychoactive Substance (NPS). These are drugs designed to replicate the effects of other substances, previously known as ‘legal highs’, therefore effects vary from drug to drug.


Mephedrone. A powder which is most commonly snorted or swallowed. It is a stimulant which can give more energy and talkativeness but also can cause a fast heart rate, anxiety, and headaches. It is sometimes said to be like MDMA but is more stimulant-like in its effects.


Nitrous Oxide. A colourless gas often inhaled from a balloon (hence why it is sometimes known as ‘balloons’). Effects are very short lived but can cause euphoria and relaxation, but also light-headedness and confusion.


Performance or Image Enhancing Drugs. These are drugs used to improve physical appearance and sporting performance, the most well known being anabolic steroids but includes a wide variety of different drugs with different effects and harms. Many of these drugs being sold in gyms are counterfeits or not designed for humans, which increases the risk.


Any other (e.g mystery pills or powders, misuse of prescribed medication).


General Health
General Health. *





Psychological Health. *





General Health
General Health *





Psychological Health *





Additional questions

Additional Questions

Additional questions

Additional Questions

Your details

Your details

Referrer full name
Referrer email
Please use numbers only
Do you have the permission of the person you are referring to share their personal information with us? * Please ensure consent is received prior to submitting the form. We are unable to process the referral if 'no' is selected.


Please confirm you have read and agree to our data protection policy