Please Choose a Referral Type

First Name*

Surname*

Role

Organisation And Address

Telephone*

Email*

First Name*

Surname*

Ethnic Group

Date of Birth*

Gender*

Address line 1*

Address line 2

Address Line 3

Postcode*

Phone*

Email address*

I wish to be contacted by text message

I wish to be contacted by email

I wish to be contacted by post

I wish to be contacted by phone

Any other contact instructions?

Do you consider yourself to be neurodivergent? (ADHD, ASD, dyslexia etc).(This information will help us adjust our support to meet your needs, and also help us to develop our services).

ADHD

ASD

Dyslexia

Dyscalculia

Dyspraxia

Disabilities / Health Conditions we should be aware of: If you will need to take medication during a session, please specify here

What is your first language?*

Do we need to contact you through an interpreter?*

I am not currently in residential / foster care*

Do you consider yourself to be a carer/young carer?

Where did you hear about us?

Other (please state)

I am over 18 and would like you to contact my next of kin in an emergency

If you have ticked this box, please make sure you have also completed the details of your parent, carer or guardian below.

First Name

Surname

Relationship to young person

Address (if different to young person)

Phone Number

Email Address

School/College/University name

GP Surgery name*

Are any other agencies supporting this young person? Please give details

Has this young person recently been referred to any other services, or are they on the waiting list for other services?

Counselling(Domestic Abuse)

Structured health and wellbeing support

Wellbeing wednesday/brief intervention

Wellbeing Café/group work

Social prescribing

Counselling

Not sure

Other

If other please specify

Anger and frustration

Anxiety

Appearance / body image

Bullying

Depression / Low mood

Domestic abuse

Exams stress

Family

Feeling safe

Finding things to enjoy

Friends

Gender identity and/or sexual identity

Housing / having somewhere to live

Loss / bereavement

Money / finances

Physical health

Problems at home

Problems at school

Relationship with food / eating disorder

Self-esteem

Self-harm

Sex / relationships

Sexual health

Traumatic life event

Work / training / education course

Other

If other please specify

Brief description of current presenting problem (including how long it's been going on for) and the impact on the life of the young person (please provide as much information as possible, as we will use this information to assess how to we can best support you) *

The information you provide on this form will be stored confidentially. Sometimes, a member of staff may want to share some of your details with another professional, for the purpose of ensuring you receive the appropriate support; this includes staff within Door43. Examples of other agencies include: Community Youth Teams, Children & Young People and Families (SCC), Housing, Police, Health Services (Including CAMHS), School and other voluntary and community agencies (including other teams within Sheffield Futures). If there are any agencies you do not wish information to be shared with, please specify here:

We will always aim to ask you before we share any information with other professionals. However, there may be some situations where this is not possible; for instance, if we are concerned for your immediate safety. For more information on our privacy policy, please ask a member of staff. Please confirm you consent to the above:*

If you are under 16 then we need consent from your parent/carer to work with you. I have had the support process explained to me and I agree to this request. I understand that this may involve an assessment of my child’s needs in order that appropriate support is planned. Please confirm parent/carer consent (if applicable)*

Please tick this box to confirm you have submitted at least one valid contact method for the Young Person. Please note without a contact method we can't get in touch to offer any support. This question is mandatory*

Are you happy for us to contact you occasionally by SMS and email about new services, upcoming events and updates from Sheffield Futures that we think you'd be interested in? *