Adolescent service self-referral form

Young person's details

This self referral form must be completed by the young person. If you are a professional referring a young person for support please use the relevant form.
Name

First name

Last name
Gender
Date of birth
Age

If you are over 25 please contact Horizon www.horizonblackpool.uk
Ethnicity
Address

Address Line 1

Address Line 2

City

County

Postcode

Country
Telephone
Mobile
Email
Legal status
School/college
Communication needs/language
GP surgery and telephone number
If under 18 are parent(s)/carer(s) aware of this self-referral and have they consented to information sharing?
Yes
Please let young people know the adolescent service will attempt to contact young people via all mediums available including telephone, email, home visits, Skype etc.