Door 43 – Referral Form

Door43 is an emotional wellbeing service for young people aged 13-25 resident in Sheffield, offering support for young people to make better choices for their future. This referral form can be completed if you are a young person seeking support for yourself, or by a professional or parent/carer on behalf of a young person.

We’ll make a decision on what form of support we can offer, and we’ll aim to let you know this within two weeks.

If you have any further questions about any aspect of our service then please get in touch on [email protected], or on 0114 201 2760.

Please click here to see our service thresholds and pathways



* indicates a field is mandatory

I am a ...



Young person's details:

What is your name?

What is your date of birth?*

What is your age?

What is your gender?
MaleFemalePrefer not to sayOther

If other please specify

What is your address?

What is your postcode?

What is your telephone number?

What is your email address?

I confirm that I have supplied at least one contact method (phone, email or address). Please note that if you do not provide any contact information then we will not be able to get in touch with you or offer you any support

What is your first language?

Do you require an interpreter?
YesNo

Are you in residential / foster care?
YesNo

How would you prefer to be contacted?
PostEmailPhoneText

Do you have any diagnosed medical condition we should be aware of?


School / college information (if applicable)

What is the name of your school / college?

Who are the key staff you are involved with & what are their contact details?

What is your ethnicity?
White BritishRomaAny other white backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed / multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black backgroundArabAny other ethnic backgroundPrefer not to say

If you answered with "Any other white background", "Any other mixed / multiple ethnic background", "Any other Asian background" or "Any other ethnic background please add details?


Parent / carer information

What is the name of your parent / carer?

What is their relationship with you?

What is their address (if different from Young Person)?

What is their telephone / contact information?


If this form is being completed on the behalf of a young person please include the referrer's information.

Your Name

Role

Organisation and address

Postcode

Telephone number

Email

Are any other agencies involved?
Social WorkerMAST / Family Support WorkerMental Health WorkerYouth Justice WorkerYouth WorkerCSE WorkerCounsellorSheffield FuturesProbation WorkerHousing ServicesOther

If other please specify

Have you recently been referred to any other agencies/services? If so, please specify


How we can help you

What support can we offer?
One-to-one wellbeing supportCounselling referralInformation and adviceSupport with work or a training courseTo know about activities and events in their areaGroup work / brief interventionHelp filling out some formsPractical supportSocial prescribingNot sureOther

If other please specify

Please state the reason for requesting support. Please provide as much information as possible, as this will help us decide on the best form of support to offer.

Which of these issues do you want support with?
Anger and frustrationAnxiety/stressAppearanceBullyingDepressionFamilyFeeling safe or feeling unsafeFinding things to enjoyFriendsGender identity and or/sexual identityHousing/having somewhere to liveLosing a family member/friendLow mood/self-esteemMental health difficultiesMoney or benefitsPhysical healthProblems at homeProblems at schoolRelationship with food/eating disorderSelf-harm or hurting themselvesSex and relationshipsSexual healthTraumatic life eventWork / training / education courseOther

If you answered other please specify


Consent

If you are under 16, your parent/carer needs to provide their consent for this referral.
 
I understand that this referral process may involve an assessment of my child’s needs in order that appropriate support is planned. I agree that the information on this form and other relevant information held by partner agencies may be shared and stored for the purpose of deciding which support is appropriate. The agencies involved are: Community Youth Teams, Children & Young People and Families (SCC), Housing, Police, Health Services (including CAMHS), School and other voluntary and community agencies.

Please tick this box to confirm that your parents have read and consented to the above

Please tick this box to confirm that the young person has read and consented to the above, and is willing to work with the Door43 team

How you can help

Our charity is dedicated to helping Sheffield's young people to reach their full potential and achieve the best out of life, whatever their starting point. To help us to do more to support young people and communities we need your help. Just remember, every penny you donate will make a difference.