First name of young person
Surname of young person
Name of parent/carer (if applicable).
Young person's DOB
Email
Tel
Preferred Method of Contact —Please choose an option— Text Call Email
If your preferred method of contact is a phone call, please let us know a good time for us to call you
Young Person's Address
Young Person's Postcode
School/College (if applicable)
GP Surgery
Does the young person know about and consent to the referral? Yes No
Reason for referral
Accessing another service? (e.g.: CAMHS, Talking Therapies, etc)Yes No Don't know
If yes, please provide name of organisation and referral reason
Has the young person accessed a crisis service in the past 3 months? (e.g.: Crisis Line, A&E, etc) Yes No Don't know
If yes, please provide details
Is the young person waiting for an assessment with the Mental Health Hub/CAMHS? Yes No Don't know
If yes, provide details
Household in receipt of benefits?Yes No
Are you happy to be added to the JDI mailing list to keep you informed of all the services we offer and when?Yes No
We will only use the data you have submitted to contact you in response to this form in accordance with our Privacy Policy. Click here to view our Privacy Policy
Our duty to ensure your safety and the safety of others is paramount. If we believe you or someone else is at immediate risk of harm as a result of the information you provide in your enquiry, we may need to take additional action. If you are unsure, you can ring us and talk through our confidentiality policy.
Please note, replies to this form will come from hello@justdropin.co.uk which might go into spam/junk folders. We will aim to respond to you within 5 working days. Please do not use this form in a time of crisis, and follow the time of crisis button on the website instead.
Christmas Challenge
