CYA - Make a referral for a young person

Please fill in the information below to make a referral.

Who is referring*

Name of Organisation if applicable

Name of referrer*

E-mail*

Phone Number*

Who is it for

15-18 years in education
18-24 years not in education, training or employment
In Care/ Leaving Care
EHCP
10 - 24 years support with emotional wellbeing

Reason for referral - please include as much information as appropriate*

Any restrictions/ support needs or safeguarding issues we should be aware of

If you know the programme you would like to refer onto please select

Is the young person aware of the referral

yes
no

Finally how did you hear about us?*

In order to provide a professional and effective service CYA need to keep a record of the personal information given in this document. All personal information is treated as private and confidential and recorded on a secure database. We will only use the personal information given for the purposes of this service and to compile statistical data for monitoring purposes. To find out more about how we process information please visit www.cya.org.uk/privacy

Please select to say you have read and understood the information above and give your written consent for Cumbria Youth Alliance to hold personal information about you/ your child/ or the young person you are referring, for the purposes of this service, and for staff/volunteers to share information with other agencies where necessary.

Our team will be in touch with you as soon as possible

Referral Form