Children and Young People's Wellbeing Referral

Children and Young People’s Wellbeing Referral

Make a referral

If you would like to make a referral on behalf of a young person you know, please complete the parents/professionals form. If you would like to make a referral for yourself, please complete our self-referral form below.

To speak to someone on our CWP team or to ask questions about the service we offer please contact us by calling 01392 410530 or emailing wellbeing@ymcaexeter.org.uk.

Your Full Name (first name and surname is required)

Date of birth (required)

Address (required)

Postcode (required)

Contact number (required)

Mood scale: Please rate how you are currently feeling, 1 = least intense, 10 = most intense. The answers to these questions will help us complete your assessment.

Sad*

Worried*

Happy*

Panicked*

Angry*

Low*

Calm*

What would you like to change about the way you are feeling? For example, if you had a magic wand that could get rid of this feeling, how would your life be different?*

How safe do you feel?
1(not safe) 10(very safe)

From yourself?*

From others?*

Overall?*

Your phone number*

Your email address

What is your preferred way for us to contact you? e.g. phone call, email

How did you find out about our wellbeing service? (required)

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Could you please let us know which school?

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Thank you for taking the time to complete this form. Please press submit so that we can begin your assessment.