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)

Could you please let us know which school?

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