YMC Strong Minds (Young Londoners) Referral Form

As part of this project, we are aiming to address psychological and mental health issues through 1:1 counselling, create healthier family relationships through parental support, motivate young people through peer mentoring, and support practical rehabilitation.
Guidelines for completing this form:
Please only refer the young person/family if they meet the following criteria:
o The child/young person must be between the ages of 10 and 21.
o The child/young person SHOULD be either at risk of exclusion or
involvement in criminal activity, or have been involved in criminal activity.
o The child/young person must be living in Barking & Dagenham or Redbridge
o If under 16, please inform the young person and their parent/carer of the referral
before referring.

Referring School / Agency / Self:

Name: *

Position:

Date of Referral:

Contact Address:

Phone: *

Email: *

Post Code:

Full Name: *

Nickname (if any)

Ethnicity:

Date of Birth:

Disability:

Risks and other important information:

Other Info If Necessary (Explain)

Parent/Guardian Name:

Guardian Email Address:

Guardian Address:

Home Number:

Mobile Number:

Work Phone:

Using the criteria above as a guide, could you briefly explain the concerns you have for this child/young person? How long has this individual demonstrated these behaviours or concerns?

I Agree to the Statement Below

>I have read and understood the information given to me regarding the services You and Me Counselling will be providing me. I understand that if I have further enquiries, I can discuss them with the staff.
> I understand that while I / the young person named above is working with You and Me Counselling, I/they/we will be subject to the service’s code and conduct of behaviour and will be required to conform with the instructions and guidance of the
service.
> I can confirm the child's parent/guardian has been informed of the referral.