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 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 To Receive Transitional Support

Please detail nature of transition If you are a young person completing this form, please don Section 1: Organisation Details Name of referrer Agency Address Town Postcode Email Section 2: Young Person Date of Birth Age Area Address Town Postcode Email Telephone Number Is the Young Person aware that this referral is being made? Section 3: Key agencies working with the Young Person Agency Name Contact Name Telephone Number Agency Name Contact Name Telephone Number Details of other agency involvement Section 4: Reason for the referral Section 5: What are the desired outcomes of this referral? Section 6: Disclosure of potential safety concerns 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) Section 7: Any other relevant information Tell us about 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