Email form

• Why do I need to complete this form? - We need to collect this information so we can arrange an appointment with a youth worker from the X2Y group, and to inform the future work of the group.
  
  
• Who sees my personal information? - Only those youth workers who run the X2Y youth group. The information will be kept on file until it is no longer needed. Your personal details will not be shared with anyone else.
  
  
• I don't feel comfortable filling out on-line forms; can't I just turn up to the group? - Yes, you can turn up at the group, but we still need your details in case of a medical emergency, and you will be asked for them when you first attend the group.
  
  
• Why do you need my email, or phone details? - We need them because we have no other way of replying to this form. So if you would like to join the group, or receive further information about the group, we'll phone, or email you to arrange a proposed time and date. (We will only use a telephone or mobile number if instructed to do so for safety and confidentiality purposes).
  
  
• How long will it take to get a reply to this form? - We will get back to you, if your contact details are correct, within 5 working days.
  
  
• I need to keep a paper record for audit purposes. - Print out a hard copy referral form (PDF format).
  
  

You must fill-in all the fields.
Help can be found by clicking on these symbols 

This form is send to:
Who are you referring?	please select...    Myself Someone else
Referrer's Details: Name:   Agency:   Job title /relationship to young person:   Phone/Email address:  (So we can reply to this form)  Have you discussed the referral with the young person?    Yes No
Young Person's Details:
Name:
Sex:	please select... Female Male		Age:	please select... under 11 11 - 15 16 - 17 18 - 25
Ethnicity:	please select... White - British White - Irish White - Other Mixed - White and Black Mixed - White and Asian Mixed - Other Asian - Indian Asian - Pakistani Asian - Bangladeshi Asian - Other Black - Caribbean Black - African Black - Other Chinese Other Ethnic Group
Location:	please select...    Wolverhampton Birmingham Dudley Sandwell Shropshire Staffordshire Telford Walsall Other - please specify...
Phone/Email address:	(So we can reply to this form)
Do you wish to speak to a female, or male worker when having the appointment?
	Female Male
What do you hope to gain from the group?
Do you wish to participate in one to one counselling?
	Yes No
Health needs/Medication/Disability:
Other details:
Retype Verification Code Here:

Your personal details will not be shared with anyone else.