Children and Young Person's 1:1 Support Referral

You have taken a brave step in asking for some help. So we can get you the support you deserve can you please complete the below form and provide as much detail as possible. Don't worry about leaving any of the spaces blank if you don't know the information.

Your Details

Your Full Name:

Your Date of Birth (00/00/0000) and Age

Your Email Address:

Your Telephone Number:

Your Address:

Are you already a member of Scotty's?

YesNoI don't know

Details of your Parent/Carer

Name of your Parent or Carer:

Relationship to you:

Does your parent/carer know you are making this referral?

YesNo

If no, are you able to give a reason why:

Parent / Carer Email Address:

Parent / Carer Telephone Number:

What does support look like for you?

Please give as much detail as possible.

Have you had any help from anyone else? (e.g teachers, other organisations, GP etc) Please let us know who they are.

What are your worries and concerns?

What is going well? (Strengths/positive, hobbies, support that has been useful? Friendships?)

What are you hoping to get from Scotty's support?

It is a courageous step asking for help and we want to provide the best possible support. One of our team will be in touch within 3 working days. If you are Under 18 we will need to make contact with your parent or carer first.

All the information you have provided is held in line with Scotty's GDPR and Data protection Regulations. You can read our privacy statement by using the link below.

Your Rights Under GDPR