Brighter Youth Registration Form
This form is for those wishing to access our Brighter Youth Talking Therapies service for those aged 8 to their 19th birthday.
Is the person being referred waiting for, or accessing CAMHS/CMHT, Social Services, counselling, or have received counselling within the last 6 months?
Yes
No
Sorry
Unfortunately we are unable to accept your referral, if you are in need of immediate support please call 111 then option 2.
Thanks
Please proceed with the rest of the form.
Introductory questions
Are you filling this form out on behalf of someone else
Yes
No
Is the young person aware you have referred them?
Yes
No
Please speak to the child/young person to confirm they are happy with you making a referral on their behalf before completing this form
Is the young person comfortable engaging with the service?
Yes
No
Please speak to the child/young person to confirm they are comfortable to engage before completing this form
About who is completing the form
As you are filling in this form on behalf of someone else, please leave your name, contact details and relationship to the person here but continue to fill out the answers in the following section as if you are the person being referred.
Your name
Your relationship to the person being registered
Teacher/Education
Parent/Guardian
Other relative
Friend
TAC
Other
Further notes on your connection to the person being registered.
If you answered 'other' please explain here:
Your Organisation
If relevant
Your email
Your contact no.
About you
(or the person you are filling this form out for)
First Name
Middle Name
Last Name
Preferred name
Gender
Male
Female
Non-binary
Prefer not to say
Preferred pronouns
Please select...
He/Him
She/Her
They/Them
He/They
She/They
Not Listed
Date of birth
For the date of birth select from calendar or type in format DD/MM/YYYY
Preferred language
Mobile Phone
Landline
Email
Address line 1
Town/City
County/Region
Post Code
Please indicate all methods you are happy for us to use to contact you (Select as many options as you want)
Mobile
Text
Voicemail
Landline
Email
Letter
Please indicate if there is a best time or day to contact you and which of the above contact methods is preferred
Please let us know why you think Brighter Youth would be of benefit
Registered GP Practice
What ethnic group do you feel best describes you?
Please select...
White (a) British [English/Welsh/Scottish/Northern Irish]
White (b) Irish
White (c) Gypsy or Irish Traveller
White (d) Any other White background
Mixed (a) White and Black Caribbean
Mixed (b) White and Black African
Mixed (c) White and Asian
Mixed (d) Any other mixed ethnic background
Asian (a) British
Asian (b) Indian
Asian (c) Pakistani
Asian (d) Bangladeshi
Asian (e) Chinese
Asian (f) Any other Asian background
Black (a) British
Black (b) African
Black (c) Caribbean
Black (d) Any other Black background
Other (a) Arab
Other (b) Jewish
Other (c) Any other ethnic group
Unknown
Do you have any accessibility requirements?
Yes
No
Storing information consent
I agree to allow Advance Brighter Futures to store and process my personal data
In order to provide you with services we require your consent to securely store data about you and the interactions we have with you. Please select today's date to show you are agreeing to ABF storing and processing your data from this point.
Thank you for completing this form
Contact Information