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Improving the mental wellbeing of young people

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Changing Minds Referral Form

Please complete this form as thoroughly as possible and with as much information as you can. Failure to complete with adequate information may result in delays.

Please be aware that you can either complete the form below, complete and send back electronically via email or download as a pdf and print, then return via post to:

Newport Mind
100-101 Commercial Street
Newport
NP20 1LU

or changingminds@newport-mind.org

If you would like to talk about this referral with someone please contact Seran Davies on:

Office: O1633 258741

Mobile: 07787 295472

Fields marked • are required.

• Date of referral • Young Person's Name Gender What are you referring the young person for (Please tick all that apply): Young Persons Advisory Panel As a Volunteer Peer Mentor Self Management Courses To receive Peer to Peer Support Receive Transitional Support Please detail nature of transition: If you are a young person completing this form please don’t worry about filling out section 1. 1. Organisation details Name of Referrer Agency Address Town Postcode Email Telephone number 2) Young Person's Details Date of Birth Age Area Newport Monmouthshire Caerphilly Torfaen Blaenau Gwent Address Town Postcode Email address Telephone number Consent- is the young person aware that this referral is beng made? Yes No 3) Key agencies who are working with the young person (if known): Agency Contact name Telephone number Agency Contact name Telephone number Other agency involvement? Give details: 4) Reason for referral 5) What are the desired outcomes of this referral? 6) Is there anything we should know about in order to stay safe around the young person? (for example, potential concerns, dangerous dogs, violent family, previous convictions) Yes No Don't know 7) Any other relevant information regarding the following categories: (If you need any help as a young person with any of the things below please let us know) Language Communication Disability Other

Be in charge of your future & make changes!

1 in 10 young people have a mental health disorder

Registered with the Charity Commission

Lottery Funded

Changing Minds, 2nd Floor, 100 to 101 Commercial Street, Newport, NP20 1LU

Tel:01633 258741 | Fax: 01633 257992 | Email:changingminds@newport-mind.org

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