Art Psychotherapy Referral Form 1) Young person's details Date Forename Surname Preferred name Contact details Date of birth School / College year Address School / College Ethnicity Country of origin First language English as Additional Language (EAL) Yes No Translator required? If so, what language? Yes No Gender Sexual orientation Religious belief / Faith Disability (access needs) Neurodivergent needs (such as autism, ADHD, dyslexia) Any medical conditions Yes No 2) Emergency Contact Name Phone number Address Relationship to young person 3) Referral details Reasons for referral / presenting issues (Please provide as much information as possible.) Is the young person at risk of harm to themselves or to others? (This doesn't mean we can't work with young people.) Yes No If yes, please provide details. (i.e. self-harm, suicide attempts, suicidal thoughts, violence towards others, drug/alcohol misuse) Young person's interests and strengths What interventions have already been accessed for this young person? (i.e. CAMHS, social services, including any current counselling or therapies, are they on any waiting lists?) Are there any safeguarding concerns we should be aware of relating to this child / young person or their family? Any other information Name Position Contact details Signed by referrer Date Will you be monitoring young person's progress in the future? Has consent been given by the child / young person for information to be shared? Yes No Thank you for completing this referral form. Please email this form to: enquiries@ycsa.org.uk Youth Community Support Agency (YCSA) Govanhill Workspace, Unit 11 69 Dixon Road, Glasgow, G42 8AT Mobile: 07902958396 Scottish Charity Number SC026233 Company Number SC313463 Safe to Grow is a 3-year project funded by the Community Lottery Fund and the Robertson Trust.
