Refer To Us

Referral Form
Do you give us consent to store and use your information in line with GDPR/Data Protection Principles to provide our services & special offers? *
A Father's child Services CIC Services. What service are you making a referral to? *
Do you have any other support in place? E.G. Social Worker, another organisation *
Circumstances we should be aware of, E.G. NEET (Not in Employment, Education or Training) *
Have you ever used A Father's child Services CIC services? *
Has anyone related to you/affiliated with you used A Father's child Services CIC services? *
Do you know anyone that works at A Father's child Services CIC? *
How enthusiastic are you/the person you are referring with wanting to make change? Use the below scale *
Do you class your self as being affiliated with a gang? *
Have you been experiencing Low Moods? *
Have you been given a clinical diagnosis by a GP or Specialist? *
Self Harming Thoughts/Behaviours *
Suicidal Thoughts/Feelings? *
Worries around behaviours with Food *
Have you spoken to anyone about how you are feeling? *
If yes, have you tested positive for Covid-19 in the past 7 days? *
Have you been in contact with someone who has had to self-isolate in the past 7 days?