Love4Life: Core Referral Form

Empowering young people aged 11-19 to build confidence and make positive choices in  their relationships, health and education. 

Love4Life aims to support and develop Young People’s  understanding of themselves. We work to empower  Young People to make positive choices in all aspects of  their lives. 

Relationships and Sex Education is one of our themes  of work, however, everything we do is about building  positive self-esteem and resilience.  

We provide honest and age appropriate resources  which cover sexual health, staying safe and potential  risk of child exploitation along with value of self, body  image and other relevant societal challenges. 

Our belief is that when young people feel good about  themselves they will make positive choices in their  health, relationships and education.

For any questions contact your local Love4Life coordinator: – Derby – Loughborough – Leicester 

Currently Love4Life only work with girls. If a referral form is incomplete or outside of our area we will contact the  referrer for resubmission or to redirect to other services. 

Section A - Young Person’s details
Please enter a postcode with a single space, e.g. LE1 1AJ
If this young person has been excluded, please provide the year group that they would currently be in if still at school/college

Primary Parent/Guardian Details
Secondary Parent/Guardian Details

Referrer's Details

I.e. are you referring yourself to Love4Life? PLEASE NOTE that you must be at least 16-years-old to refer yourself
This could be your job title or your specific role
Please provide details of the agency for which you work:
I.e. as it appears on Companies House or Charity Commission records
Other Professionals Involved

Please provide any details or context you feel are relevant

To add details of another professional, click the 'Add another response' link below
Reasons for Referral
Please tick all boxes that apply

Parent/Guardian consent (can be completed by young person if 16 or above) 

Love4Life also require the referrer to gain parental/guardian consent in order to complete this referral. 

If for any reason you are not able or is it not appropriate to gain parental consent, please contact Love4Life.  

In line with GDPR, once a referral has commenced, we will ask the Young Person (if they are over 14 years old) to agree  with and sign our Young Person’s Privacy Notice. If the Young Person is 11-13 years old, we will ask them to take the  Privacy Notice home to be signed by their parent/guardian and returned to us. 

Once we have received the referral form the Young Person will be added to our waiting list. We shall then contact  the Young Person via their preferred method of contact to arrange an initial assessment.