Get support for myself

Provider *

Select the provider on the dropdown menu which is your first choice of service.

Name

Date of birth

Email *

Phone Number *

Address *

Do you go to school, college or university? If yes please let us know where.

Is there someone that we could speak to at your school, college or university?

Ethnicity

Other – Ethnic group

Gender

Other Gender – Please specify

Sexual Orientation

Other Sexual Orientation – Please specify

Do you consider yourself to have a disability or additional needs?

Yes
No
Prefer not to say

If yes please specify e.g. Sight, Learning, Mobility

Are you an asylum seeker/refugee?

Yes
No
Prefer not to say

Are you a young carer?

Yes
No
Prefer not to say

Are you a looked after child?

Yes
No
Prefer not to say

A child or young person who is being cared for by their local authority

What do you need help or support with? *

Please include information about the problem you are experiencing, any support you have from family/friends/professionals, how long have you felt like this, if you are aware of or have been using any coping strategies to support these feelings.

Are you pregnant?

Yes
No

Are you currently in education?

Yes
No

Are you working with social care?

Yes
No
Unknown

Are you currently in any risk of danger or harm?

Yes
No

- Call 999 if you or someone else is in immediate harm or danger.

- Guide-Line is our free chat and telephone service for emotional support and guidance on mental health. Available everyday 12pm-12am for people in the Bradford district.

- Call First Response on 0800 9521 181 if you need urgent mental health support and live in the Bradford district or Craven, open 24/7. Anyone of any age can call First Response.

What to expect next

Someone will be in touch in the next 5 working days to confirm receiving your referral and explain what happens next.

Full details on how we use your data and keep it safe can be found in our Privacy Policy.

Youth in Mind

What to expect next

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