Youth in Mind

Get support for someone else

• Before you complete the form please make sure you read the information about the different Youth in Mind services available.
• Check which service the child or young person is eligible for here. 
• Please complete the top three fields with your details and the rest of the form with the young person’s information.
• If you need any help completing the form then please contact [email protected]

Provider *Select...Buddies Inspire Young & Healthy People M.A.G.I.C Mighty Minds

Select the provider on the dropdown menu which is your first choice of service for the person you are referring.

Is the Young Person aware of and do they consent to this referral? *

• Please tick this box to confirm the child you are referring have given express consent to you making this referral and sharing their information with us:

If you do not have the express consent of the child or young person, please obtain consent from them before making a referral.

Are you a Parent, Carer or Professional?Select...ParentCarerProfessional

What kind of professional

Name of Professional/Parent/Carer Referring

Referring Organisation & Address (If appropriate)

Professional/Parent/Carer Contact Telephone Number

Young Person's Name

Young Person's Date of birth

Young Person/Parent/Carer Email *

Young Person/Parent/Carer Phone Number

Young Person's Address

Young Person's school, college or university

Contact of someone at school, college, university named above

Ethnicity

• Asian or Asian British - Bangladeshi
• Asian or Asian British - Indian
• Asian or Asian British - Pakistani
• Asian or Asian British - Any other Asian background
• Black or Black British - African
• Black or Black British - Caribbean
• Black or Black British - Any other Black background
• Mixed - White and Asian
• Mixed - White and Black African
• Mixed - White and Black Caribbean
• Mixed - Any other mixed background
• White - English, Welsh, Scottish, British
• White - Irish
• White - Central and Eastern European
• White - Gypsy / Roma / Traveller
• White - Any other white background
• Other - Arab
• Other - Chinese
• Other - Latin American
• Any other ethnic group

Other – Ethnic group

Gender

• Male
• Female
• Non-binary
• Other
• Prefer not to say

Other Gender – Please specify

Sexual Orientation

• Straight
• Lesbian
• Gay
• Bisexual
• Asexual
• Unsure
• Other
• Prefer not to say

Other Sexual Orientation – Please specify

Do they consider themselves to have a disability or additional needs?

• Yes
• No
• Prefer not to say

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

Are they an asylum seeker/refugee?

• Yes
• No
• Prefer not to say

Are they a young carer?

• Yes
• No
• Prefer not to say

Are they a looked after child?

• Yes
• No
• Prefer not to say

What do they need help or support with? *

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

Are they pregnant?

• Yes
• No

Are they currently in education?

• Yes
• No

Are they working with social care?

• Yes
• No
• Unknown

Are they 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.

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