Please choose a referral type*

First Name*

Surname*

Ethnic Group

Date of Birth*

Gender*

Is your gender identity the same as the sex you were assigned at birth?

Address line 1*

Address line 2

Town

Postcode*

Phone*

Email*

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? (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 need to be aware of? If you will need to take any medication during a session, please specifiy here

What is your first language?*

Is an interpreter needed?

Accommodation Type*

Is this a 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 tick this box please make sure you have also competed the details of your parent, carer of guardian below).

School/College/University name

GP Surgery*

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?

Social prescribing

Wellbeing wednesday/brief intervention

Wellbeing Café/group work

Structured health and wellbeing support

Counselling

Domestic Abuse Counselling

Art Therapy (1:1)

Art Therapy (Group)

Not sure

Other (please specify)

Anger and frustration

Anxiety

Appearance / body image

Bullying

Depression / Low mood

Family

Feeling safe

Finding things to enjoy

Friends

Gender identity and/or sexual identity

Housing / having somewhere to live

Loss / bereavement

Self-esteem

Mental health difficulties

Money / finances

Physical health

Problems at home

Problems at school

Relationship with food / eating disorder

Self-harm

Sex / relationships

Sexual health

Traumatic life event

Work / training / education course

Domestic abuse

Exams stress

Concerns about the future

Brief description of presenting problems (including how long its 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 we can best support you)*

If there are any people or 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*

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