Consent to Hold Personal Information

Before proceeding to your self referral form, we just need to ask some questions to check whether we can offer you support.


Do you consent for us to hold the personal information you give us in this form?

We can only offer you support if we can hold your information, for example if we need to contact you. If you want to continue, please provide your consent. If not, please see what other support might be available to you: here

Next

 

Catchment Area Check

To make sure you live in the area and age range we can provide support for, please fill in the information below.


What is your date of birth?


What is your postcode?


Are any of these true?

Please choose one or more where applicable.

Next

 

Your Support Needs

Please let us know what you would like support with.


What is it that you would like support with?

You can tick as many of these as you need to.

Which of these is the main thing, in your opinion?



Please tell us more about this


Next

 

Your Contact Information

Please provide us with as much information as possible about yourself and your contact details.


If you cannot find your GP, please select the ‘Cannot find GP’ option.

Do any of these apply to you?

Please select as many as apply

Please make sure you've given us enough information to contact you, either by phone, text, email or post.

How would you like us to contact you?



Do you have your parent/carer's consent for us to contact them?

If you don't have your parent/carer's consent for us to contact them on your behalf, please choose a different option for how we can contact you above.

Next

 

Parent/Carer's Consent

Finally, please provide us with as much information as possible about your parent/carer.


Does your parent/carer consent for you to give us their personal information?


Next

 

Parent/Carer's Information

Finally, please provide us with some information about your parent/carer.



What is the best way to contact them?

Please make sure you've given us enough information to contact them.


 

Contact Us


HYA Partners