Love4Life: Core Referral Form

Empowering young people aged 11-18 to build confidence and make positive choices in their health and relationships. 

Love4Life specialises in supporting vulnerable girls* in Leicestershire, Leicester & Derby to develop their self-esteem and form positive and empowering relationships by offering Love4Life groups, one-to-ones and workshops at school and in the community.

We deliver targeted relationship and sex education to support young people facing difficulties in these areas and provide honest and age-appropriate resources to help them understand their sexual health, how to stay safe and the potential risk of sexual exploitation.

All of our work embeds positive self-worth, body image and the handling of emotions in order to help a young person become more resilient. Our belief is that once young people feel good about themselves they are more likely to make positive choices in their health and relationships.

For more information on whether a young person is suitable for our support visit Our Young People (

For details of the types of support we offer go to Our Love4Life Services (

For any questions contact your local Love4Life coordinator: 

*Currently Love4Life works with those who identify as girls, or who experience the particular challenges associated with being born female or presenting as female. If you’d like to discuss further whether our service is right for a particular young person then please get in touch.

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

The following information helps us to better understand our service users and ensure we are providing a diverse and inclusive service.  If you or the young person are not comfortable sharing this information you can leave it blank.

Section B  - Parent/Guardian details 

(If you are over-16 and self-referring please provide your contact details here as well)

Primary Parent/Guardian Details
Secondary Parent/Guardian Details (optional)
Section C - 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
Referrer's Details
This could be your job title or your specific role
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
It is important to ensure that both the young person and their parent/guardian are aware that a referral is being made and have consented to their information being shared. 
Yes No

Reasons for Referral
Please tick all boxes that apply

Yes No

*Please note we are not a specialist mental health charity.  Where a young person’s needs are exclusively or predominantly linked to their mental health, or they are experiencing crisis symptoms (e.g. suicidal thoughts, severe self-harm), they will be better with specialist support.  

We are always happy to work alongside mental health professionals to provide more informal support, such as Love4Life groups, to address issues like self-esteem, body image and social anxiety where appropriate.

If in doubt, please get in touch with us to discuss it further.

We may get in touch with you, or other professionals whose details have been provided here, to discuss this referral in more detail before accepting the young person onto our programme.

In line with GDPR, we will also need to confirm written consent from the parent/guardian for the referral and will speak to the young person to check they wish to proceed with our support.  At this point the young person will be provided with a Privacy Notice, which they will need to agree to in order to access our services.  

If for any reason it is not appropriate to gain parental consent, please contact us.