Family Member & Concerned Others

Online Referral Form

Complete this form to make a referral to Family Service (provided by WithYou)

Family Worker Referral form

Family Worker Referral form

Are you making a referral for a Young Person or a Family Member/Concerned Other

Select one option *

We Are WithYou for Family Member & Concerned Others

We provide free and confidential support to Family Members & Concerned Others 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

Details of Family Member or Concerned Other 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 Family Member/Concerned Other know about this referral?
Has the Family Member/Concerned Other consented to this referral? Please ensure consent is gained prior to making the referral.
Contact details of the person you are referring

Details of the person you are referring

Please enter a residential town
Does the person you are referring have a fixed address? *
Please select Ethnicity from the drop down menu.
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