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Canvas of Hope

Healing Through Creativity — Agency / Professional Referral

Important: YCSA is not a crisis service. If the person referred is experiencing a mental health emergency, please contact NHS 111 or emergency services immediately.

Agency Professional Referral Form

"*" indicates required fields

1. Referrer Information

Date of Referral
Has consent been obtained?

2. Young Person / Family Details

Date of Birth*
Interpreter Required?

3. Emergency Contact

4. Referral Reason / Presenting Issues

5. Current Agencies Involved

Safeguarding Concerns?

6. Referrer Recommendations

7. Consent Declaration

I confirm that the young person and/or their parent career has been informed about this referral and agrees to their information being shared with YCSA for the purpose of support and assessment.
Date*
Date*
Date*