Galaxy-Speak Up-Young person’s referral form - Young person's referral form

Your privacy

Please only use this form to send information which is relevant to your referral.

We will handle your referral confidentially. For more information about how we handle your personal data see our Privacy Notice (link opens in new window).

Do you agree with the Privacy Notice? ((required))

Yes, I agree to the Privacy Notice

Your full name ((required))

Date of birth ((required))

Contact telephone ((required))

Contact email address ((required))

Do any of the following apply to you? ((required))

I am in care

I am a care leaver under the age of 25

I have a Child Protection Plan

I am a parent under the age of 18 and my child has a Child Protection Plan

I am aged 16 or 17 and homeless

I would like to make a complaint about a council service

Please select all that apply

Please advise what support you need from an advocate ((required))

Do you wish to receive a copy of your referral by email? ((required)) Your copy will be sent to the email address provided.