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YourSpace - Self Referral Form

Children or Young Person Details


Parent/Carer Contact Details (if under 18) / Emergency contact details


Reason for Referral

• A description of any emotional and wellbeing difficulties you/your child might be having.
• How long have these been affecting you/your child.
• What impact have these had on you/your child, and have it had any impact on your family, school/work, or friends?
• Have there been any big family events or illnesses recently?
• The more information you include, the better we can decide on how best to support you or your child

Data Protection, Information Sharing

I consent to ONSIDE storing and using the personal information I have provided and understand how ONSIDE will use personal data and my rights: