Youth Service: professional referral for help and support

Referrer's contact details
Your contact details as an employee of a school or agency.
Your first name
Your last name
Name of your school or agency
Your job title
Work email address
Phone number
Address of school or agency

Details of young person
Young person's full name
Young person's date of birth (DD/MM/YYYY) Example 1 May 2010 is 01/05/2010
Young person's gender
Contact phone number for young person
School / college
Attendance percentage
Young person's address

Please enter a Denbighshire postcode and then click the 'Find address' button.

Alternatively, please type in your address below.
Postcode
Address line 1
Address line 2
Address line 3
Address line 4
Address line 5

Additional information
Can the young person speak Welsh?
A littleFluentNo
Does the young person consider themselves to have a disability?
YesNo
Does the young person have an additional learning need?
YesNo
Is the young person a 'Looked After Child' (LAC)?
YesNo
Reason(s) for referral
BullyingEmotional supportMental wellbeingExploitationConfidence / self-esteemHomelessness prevention16-17 crisis homelessnessOther (please state below)
Other information or needs
Please give as much detail as possible including whether there are safeguarding concerns.
Is there any other information or any other needs you want to tell us about?

Consent
The data you have provided will be used by Denbighshire County Council for the specific purpose of your referral to Youth Services. Denbighshire County Council will share your data with other colleagues if needed to support your referral. Denbighshire County Council will retain this personal data for 3 years. If you feel that Denbighshire County Council have mishandled your personal data at any time you can make a complaint to the Information Commissioners Office by visiting their website or by calling their helpline on 0303 123 1113. For further information about how Denbighshire County Council processes personal data and your rights please see our privacy notice.
Do you consent to this information being held electronically in accordance with Data Protection Act requirements?
Yes

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