REFER TO OUR ADVOCACY SERVICES If you would like to speak to an Advocate, please fill out the form below. You might want to read about our different Advocacy services first. We will be in touch within 3 working days of receiving the form, or if it is urgent, within 24 hours (weekdays only). Referral Form Name of Young Person * (if this referral is for more than one child / multi young people from the same family please use the notes box below to give us the name and DOB of additional children) First Name Last Name Preferred name of Young Person If different from above First Name Last Name Date of Birth of Young Person * MM DD YYYY Address & Postcode of Young Person Address 1 Address 2 City State/Province Zip/Postal Code Country Ethnicity of Young Person This question is optional White: British, English, Welsh, Scottish, Northern Irish, Irish, Eastern European, Any other white background Asian or Asian British: Indian, Pakistani, Bangladeshi, Chinese, Any other Asian background Black or Black British: African, Caribbean, Any other black background Middle Eastern: Afghan, Arab, Kurdish, Iranian, Any other middle eastern background Gypsy or Traveller: Irish traveller, Romany Gypsy, Any other Traveller or Gypsy background Mixed: White and Black Caribbean, White and Black African, White and Asian, Any other mixed background Other: Hispanic or Latin American, Any other ethnic group Not known Prefer not to say Gender of Young Person This question is optional Female Male Non Binary Trans Agender Demi Gender Fluid Gender-Queer Intermediate Other Unsure/questioning Young person prefers not to say Unknown Name of Referrer/You * First Name Last Name Phone Number of Referrer * Job Title/Organisation of Referrer Email address of Referrer * Notes This field is only for adding detail of multiple young people if required. Please move on to the next field if you are only referring one person. Reason for Advocacy referral * Is the young person aware of the referral? * Yes No Contact details (name and tel no) of adult with parental responsibility We need this to ask permission to speak / meet with the young person If the young person wishes to be contacted directly please give their telephone number: Once we have consent from the adult with parental responsibility, we will contact the young person directly. Any specific communication or accessibility needs? eg SEND, language, sensory needs, emotional needs Any concerns about us visiting the young person at home and / or school? Anything else we should know? eg recent bereavements or significant events Does the young person have an Education, Health and Care Plan? Yes No Unsure Date of any upcoming meetings, for example CPC, CIC Review, EHCP Review Please state type of meeting – details will be followed up with a phone call. How would you like us to contact you? Text Call Email Thank you. We will be in touch as soon as possible. DONATE AND HELP SUPPORT LOCAL YOUNG PEOPLE
