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Drug Support
Alcohol Support
Support for young people aged 18 and under
IPS Employment support service
Intensive Family Support Service (IFSS)
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Free Online Self-Help Programmes
5 ways to wellbeing
Exercise and the benefits
Self-help and useful links
Contact us
Need our support?
Make a referral
To refer a young person please see the form below:
Young Person Referral Form
Are you completing this form for yourself?
(Required)
Yes
No
Are you a professional referring someone else?
(Required)
Yes
No
Referrer’s Details
The details of the professional who is referring someone to the service.
Your Name (referrer)
First Name
Surname
Contact Number
Email Address
Your Organisation
Referree's Details
The details of the person who is being referred to the service.
Name
(Required)
First Name
Surname
Address
(Required)
Street Address
Address Line 2
City
County
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Date of Birth
(Required)
DD slash MM slash YYYY
Nationality
(Required)
Preferred Language
Contact Number
(Required)
Email Address
(Required)
Gender Identity
(Required)
Male (including trans male)
Female (including trans female)
Non-Binary
Prefer not to say
Other
Pronouns
Do you have any disabilities or learning needs?
(Required)
Yes
No
If you feel comfortable doing so, please detail your disabilities or learning needs
Are you registered with a GP?
(Required)
Yes
No
Name of GP and GP Practice
Are you currently receiving support for your mental health?
Yes
No
Prefer not to say
If yes, who are you currently working with to support your mental health?
How can we contact you?
(Required)
Call
Text
Email
Post
Select All
Please tick each appropriate item
Can we contact you at home?
(Required)
Yes
No
Are your parent/s or guardian aware of your referral?
(Required)
Yes
No
The name of your parent/s or guardian
Contact number for your parent/s or guardian
Please only enter one phone number
Where would you like to be seen?
(Required)
Burton
Leek
Newcastle-under-Lyme
Stafford
Tamworth
Please select a location from the dropdown menu
Do you require an interpreter?
Yes
No
Are you pregnant?
(Required)
Yes
No
Do you drink alcohol?
(Required)
Yes
No
Sometimes
How much do you drink and how often?
Does alcohol cause you any concern?
Yes
No
Concerns could be physical health, emotional health, family and relationships, housing, employment, education, finances, or illegal activities.
Do you use drugs?
Yes
No
Sometimes
What drugs do you use, how much do you use and how often?
Do drugs cause you any concern?
Yes
No
Concerns could be physical health, emotional health, family and relationships, housing, employment, education, finances, or illegal activities.
Support around someone else's drug or alcohol use
Would you like to receive support around a family member's, carer's or guardian's drug or alcohol use?
Yes
No
What impact does their drug and/or alcohol use have on you?