Agency Referral Form

If you would like to make a referral to one of our projects / services, please complete the form below.

Please be aware that any information submitted via this form will be treated with the strictest of confidence in line with our GDPR policies. You can find out more about how we use information in our privacy policy at https://ervas.org.uk/privacy-and-cookies/.

All information received will be emailed directly to the appropriate member of the Volunteen team, who will then contact you accordingly.

We aim to respond to any referrals within 2 to 3 working days, if you have not heard from us before this time, please call 01482 871 077 or email VolunteenPlus@ervas.org.uk.

Young Person's Full Name *

First

Last

Young Person's Date of Birth *

Young Person's Contact Address

Young Person's Contact Number

Name of Person Making Referral *

Agency / Service Making Referral *

Email for Referring Agency *

Confirm Email

Additional Contact Details for Referring Agency *

Please state any other agencies working with the young person along with their contact details *

Young Person's Current Situation

Supporting Information

Please give details if the young person has any of the following needs in relation to: Special Educational Needs and Disability, emotional health and mental well-being, Substance/alcohol misuse, youth offending, anti-social behaviour, speaking English as an additional language, having additional supervision requirements i.e. on a 2:1 basis, any other identified needs. (please include any known triggers that relate to the above needs, and successful strategies)

The young person has been notified and consented to this referral has been made *

Name