Refer To Us Referral Form Referring Organisation/Person (Enter N/A if not applicable) * First Name: * Last Name: * Please specify your gender? * Please specify your Ethnicity? * Please confirm your age? E.G 24 * Date of Birth: * Do you give us consent to store and use your information in line with GDPR/Data Protection Principles to provide our services & special offers? * Yes No Phone No: * Mobile Phone No: Email * Address 1: * Address 2: * Address 3: Town/City: * Postcode: * A Father's child Services CIC Services. What service are you making a referral to? * Counselling Mentoring Workshops The Therapy Hub Other programmes when funding is available Energy Advocacy Project How would you like us to contact you? E.G. Phone, text, Email other * How did you become aware of the service? * Do you have any other support in place? E.G. Social Worker, another organisation * Yes No If Yes, please provide more information * Circumstances we should be aware of, E.G. NEET (Not in Employment, Education or Training) * Yes No If Yes, please provide more information. E.G. How long, any other issues * Tell us what support you think could help? * Have you ever used A Father's child Services CIC services? * Yes No Has anyone related to you/affiliated with you used A Father's child Services CIC services? * Yes No If so, do you know the name of the Practitioner that supported them? Do you know anyone that works at A Father's child Services CIC? * Yes No If so who? How enthusiastic are you/the person you are referring with wanting to make change? Use the below scale * 1-2 Stuck 3-4 Accepting Help 5-6 Motivated and Taking Responsibility 7-8 Learning what works 9-10 Self Reliant Do you class your self as being affiliated with a gang? * Yes No If so, what area/s are you associated with? E.G B19, B21 URGENT INFORMATION ABOUT THIS YOU THINK WE SHOULD KNOW (Enter N/A if nothing applies) * Other please specify? E.G. Domestic Violence/Grooming? (Enter N/A if nothing applies) * Please describe what may be worrying you. (Enter N/A if nothing applies) * Have you been experiencing Low Moods? * Yes No If so How Long? E.G. 2 weeks, more than a month. Have you been given a clinical diagnosis by a GP or Specialist? * Yes No If Yes please specify. Self Harming Thoughts/Behaviours * Yes No Suicidal Thoughts/Feelings? * Yes No Worries around behaviours with Food * Yes No Have you spoken to anyone about how you are feeling? * Yes No Other If Yes or other, Please state who? * What support if any do you already have in place? If Nothing in place advise N/A * Have you or anyone in your household suffered from Covid-19, Flu like symptoms, a temperature or been in contact with someone that has in the past 7 days? * If yes, have you tested positive for Covid-19 in the past 7 days? * Yes No Have you been in contact with someone who has had to self-isolate in the past 7 days? Yes No Submit
