Manchester Mind CYP Services Referral Form

Referrer

First Name

Last Name

Phone Number

Your Contact Details

Your contact details will be held on Manchester Mind's database, which can only be accessed by current Manchester Mind staff.. We will not share these with any other organisation. We will use these details if there is an issue with the referral (e.g. we cannot make contact with the young person, or we need further details about their situation), a member of Manchester Mind staff may contact you for more information. For more details of how we hold personal data please see our Data Privacy Notice.

Who is this referral from?

How did you hear about us?

Another Manchester Mind service

Family or friend

Other

Other Organisation

Previously used our services

Saw a presentation

Search engine

Social Media

Please describe how you heard about Manchester Mind- if not listed.

Referring Organisation

Organisation Name

Address Line 1

Address Line 2

Address Line 3

Town/ City

Postal Code

Phone Number

Is the young person aware that a referral is being made on their behalf, and that their details are being shared with Manchester Mind's Children and Young People's Service?

Yes

Please make sure the Young Person is aware Manchester Mind will be in contact with then before continuing with this referral.

Young Person

First Name

Last Name

Their preferred pronouns (if known)

Address Line 1

Address Line 2

Address Line 3

Town/ City

Postal Code

Country

Mobile

Phone

Preferred Communication Method(s)

Phone

SMS

Contact Preference Notes

Any information about how and when this young person prefers to be contacted. The best timeand method to contact them. Is it ok to leave a voice message or send an SMS.

Manchester Mind CYP Services- Eligibility

Manchester Mind Children and Young People's Services
Counselling Service Open to young people aged between 15 and 25 who live in Manchester.

Peer Support Groups Open to young people aged between 18 and 25 who live in Manchester.

If the young person you are referring doesn't live in Manchester, or is under 15, you can still complete this referral form or you can call 0161 769 5732. We will try to signpost you to services that are able to help.

Are they a Manchester Resident? Does the young person (or their family) pay Council Tax to Manchester City Council?

Yes

Don't know

Not sure of your local council? Find out using this postcode search.

Birth Date

Referral Details

What would you like Manchester Mind to help you with?

Preferred Language

Interpreter needed?

Yes

Most of our services are conducted in English. We are able to offer some of our services in Hindi, Urdu, and Punjabi. For other languages we use the help of an interpreter where we can. Please let us know if you would like to explore this option.

Risk Outline

Is the young person a risk to themselves or others?

Yes

Don't know

Please give a brief overview of any risks Manchester Mind may need to be aware of

Are any other agencies involved?

Yes

Please list other agencies

GP, Psychiatrist, CPN- Community Psychiatric Nurse, Social Worker etc