External Referral Form

Young person's details

Forename(s)

Last Name

Date of Birth (dd/mm/yyyy)

Age

Is the young person's gender different or does have more components to the one assumed at birth?

What is their gender identity?

Additional gender identity

Let us know if they have other identities we should be aware of.

Pronoun mostly used

Other pronoun mostly used

Pronoun sometimes used

Other pronoun sometimes used

Sexuality

If sexuality other, please specify

Ethnicity

Country of origin

Place of birth

Immigration status

Immigration status - other

Does the young person have a Faith or Religion?

Does the young person's family have a faith/religion?

Does the young person consider themselves to have a disability?

If the Young Person has had a condition for more than 12 months.

If yes, please provide relevant details:

Does the young person have any access requirements?

Young person's contact information

Main Telephone Number

Email Address

Address Line 1

Address Line 2

Address Line 3 (Town)

Postcode

The post code must be in a valid UK format to submit the form (or it can be left blank).

If the young person has nowhere to live, where is their nearest city?

Emergency Contact

Include name, relationship and contact details

How would they prefer us to contact them?

Specify if Other

Our opening times are 9am – 5pm, Monday to Friday. When is it best to contact them?

Please tell us about any safety concerns you have about how and when we contact them?

Safe to call?

Safe to Whatsapp?

Safe to email?

Safe to text?

Type of housing

Have they ever experienced rough sleeping?

Preferred language

Interpreter required?

Details of referral

What support do you want AKT to provide?
What support are you/will you be providing to the young person?

Have you identified any risks AKT should be aware of?

If you have completed a risk assessment with the young person that you want to share, please upload the details of this here.

Referrer Details

Referrer First Name(s)

Referrer Last Name

Organisation

Referrer main phone number

Referrer e-mail address

How did you hear about us?

Details - how you heard about us?

Is the young person aware you are making this referral?

Contact Information