Referral form

Thank you for your referral - we will be in touch within three working days.

If you have any questions about our service or feedback on our referral form, please contact help@hopesupport.org.uk

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https://hopesupport.org.uk/support/refer

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This referral is for...

--Select--

Herefordshire

Forest of Dean

Anywhere else in the UK (online support)

I am a...

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Young Person

Parent/Family Member

Professional

Full name:

Address:

Email address:

Phone number:

Date of Birth:

If you're referring yourself to our face-to-face service, please let us know about any allergies/medical conditions we need to be aware of:

Gender:

Ethnicity:

Reason for referralPlease explain who is ill, and which illness they have

How did you hear about Hope?

Please provide an emergency contact name, phone number and how you know them - this will only be used if we are worried about your safety, in line with our safeguarding procedure.

Name:

Phone number:

How do you know them:

Your name:

Your organisation:

Your phone number:

Your email address:

Reason for referralPlease explain who is ill, and which illness they have

Emergency contact name, relationship to child and phone number:

Your name:

Your phone number:

Your email address:

Reason for referralPlease explain who is ill, and which illness they have

If you are not the emergency contact, please provide a name, phone number and relationship to the child:

Where did you find out about Hope?

Young person's details

Full name:

Address:

Email address:If they are too young or do not have one, please leave blank or provide a parent/carer's email address

Phone number:If they are too young or do not have one, please leave blank

Date of Birth:

Gender:

Ethnicity:

Is there anything else we should know about this child/young person?

If you are referring to our face-to-face service, please provide details of any medical conditions or allergies we need to be aware of:

The child/young person needs to be aware of the diagnosis and referral before we are able to work with them. Can you confirm if the child/young person is aware?

Yes

Would you like to refer another child?

Yes

Young person's details

Full name:

Address:(leave blank if their address is the same as previous child)

Email address:If they are too young or do not have one, please leave blank or provide a parent/carer's email address

Phone number:If they are too young or do not have one, please leave blank

Date of Birth:

Gender:

Ethnicity:

Is there anything else we should know about this child/young person?

If you are referring to our face-to-face service, please provide details of any medical conditions or allergies we need to be aware of:

The child/young person needs to be aware of the diagnosis and referral before we are able to work with them. Can you confirm if the child/young person is aware?

Yes

Would you like to refer another child?

Yes

Young person's details

Full name:

Address: (leave blank if their address is the same as previous child)

Email address:If they are too young or do not have one, please leave blank or provide a parent/carer's email address

Phone number:If they are too young or do not have one, please leave blank

Date of Birth:

Gender:

Ethnicity:

Is there anything else we should know about this child/young person?

If you are referring to our face-to-face service, please provide details of any medical conditions or allergies we need to be aware of:

The child/young person needs to be aware of the diagnosis and referral before we are able to work with them. Can you confirm if the child/young person is aware?

Yes

Would you like to refer another child?

Yes

Young person's details

Full name:

Address:If the address is the same as the previous child, please leave blank

Email address:If they are too young or do not have one, please leave blank or provide a parent/carer's email address

Phone number:If they are too young or do not have one, please leave blank

Date of Birth:

Gender:

Ethnicity:

Is there anything else we should know about this child/young person?

If you are referring to our face-to-face service, please provide details of any medical conditions or allergies we need to be aware of:

The child/young person needs to be aware of the diagnosis and referral before we are able to work with them. Can you confirm if the child/young person is aware?

Yes

Would you like to refer another child?

Yes

Young person's details

Full name:

Address:(leave blank if their address is the same as previous child)

Email address:If they are too young or do not have one, please leave blank or provide a parent/carer's email address

Phone number:If they are too young or do not have one, please leave blank

Date of Birth:

Gender:

Ethnicity:

Is there anything else we should know about this child/young person?

If you are referring to our face-to-face service, please provide details of any medical conditions or allergies we need to be aware of:

The child/young person needs to be aware of the diagnosis and referral before we are able to work with them. Can you confirm if the child/young person is aware?

Yes

Please provide an emergency contact name, phone number and how you know them - this will only be used if we are worried about your safety, in line with our safeguarding procedure.

Young person's details

Young person's details

Young person's details

Young person's details

Young person's details

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