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      First name of young person

      Surname of young person

      Name of parent/carer (if applicable). PLEASE NOTE: WE ONLY TAKE REFERRALS DIRECTLY FROM YOUNG PEOPLE/FAMILIES, NOT EXTERNAL ORGANISATIONS, INCLUDING GP SURGERIES.

      Young person's DOB

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      Tel

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      Young Person's Address

      Young Person's Postcode

      School/College (if applicable)

      GP Surgery

      Service (please click inside box below to select a service)

      Does the young person know about and consent to the referral?

      Reason for referral

      Accessing another service?

      If yes, please provide name of organisation and referral reason

      Has the young person accessed a crisis service in the past 3 months?

      If yes, please provide details

      Is the young person waiting for an assessment with the Mental Health Hub/CAMHS?

      If yes, provide details

      Household in receipt of benefits?

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      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.

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