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Canvas of Hope

Healing Through Creativity — Family / Young Person Referral Form

Family / Young Person Referral Form
Youth Community Support Agency (YCSA)
Govanhill Workspace, 69 Dixon Road, Glasgow G42 8AT
📞 0141 420 6600 | 🌐 www.ycsa.org.uk | ✉️ enquiries@ycsa.org.uk
Assistance is available for completing this form in your preferred language or if you need help. YCSA is not a crisis service. If you are experiencing a mental health emergency, please contact NHS 111.

Family Young Person Referral

1. Referral Details

Date Received
Referred By

2. Young Person Details

Date of Birth(Required)
Interpreter Required?

3. Parent / Caregiver / Guardian Details

Interpreter Required?

4. Emergency Contact Details

5. Family Structure

6. Reason for Referral

Please tick all that apply:

7. Current Supports

8. Consent and Data Protection

I understand that my information will be kept confidential and used only to provide support through YCSA’s Canvas of Hope programme. Information will not be shared without my consent, except if someone is at risk of harm or if required by law. I agree to participate and allow relevant information to be shared with programme staff.

9. Ethnic / Cultural Background

10. Immigration Status

Referred By

11. Data Protection & Signatures

Date(Required)
Date(Required)