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Brent Young People Thrive Referral Form
Submitted by
circleinteractive
on Thu, 16/04/2026 - 11:11
Are you a professional or parent/carer?
*
Yes
No
Professional or parent/carer details
First Name
*
Last Name
*
Organisation
Phone Number
*
Email
*
Reason for referral? Please Note: this is a short term therapy service. Therefore we do not see clients with severe and enduring mental health difficulties such complex trauma, OCD, psychosis and personality disorder)
*
Young Person's Details
Brent Lyra works with other organisations.
Can you confirm we can share your information with partners to ensure you receive
the best service suitable to meet your needs, by ticking the box.
Data sharing consent
*
Yes
No
Reason why consent withheld
*
First Name
*
Last Name
*
Birth Date
*
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Street Address
*
Street Address Line 2
*
Street Address Line 3
City
*
Postal Code (Home)
*
If in education, please provide the full details of your school or college
Street Address 2
City 2
Postal Code 2
State/Province 2
Mobile Phone Number (so we can send you a SMS reminder)
*
Contact Email
*
NHS number (Data purposes only for local need)
GP name and address (Data purposes only)
Ethnicity
*
White-British
White-Irish
Any other White background
Black/Black British-Caribbean
Black/Black British-African
Any other Black background
Black Caribbean and White
Black African and White
Asian and White
Any other mixed background
Chinese
Bangladeshi
Indian
Pakistani
Any other Asian background
Any other ethnic group
Prefer not to say
Not known
Do you speak/understand English?
Yes
No
If not, tell us what language you speak?
Would you require an interpreter?
Yes
No
What areas would you like to focus on?
*
Building self esteem
Confronting anxiety provoking situations
Managing difficult emotions
Other
If other, please tell us what.
Below are the conditions we work with, please select the appropriate condition
Anxiety
Emotional Dysregulation
Exam Stress
Low Mood
Phobias
Panic Attacks
Sleep Difficulties
Stress
Unhealthy Habits
Worry
Please tell us more if you can?
Onset: When did this mental/emotional health problem start?
*
With this support what changes would make your life better?
*
Are you living with any long-term health conditions?
*
Yes
No
Are you taking any psychiatric medication?
*
Yes
No
If yes, please state what
Have you experienced any difficult or distressing events that still affect you now?
*
Yes
No
Prefer not to say
Do you have any additional educational needs, i.e. Dyslexia?
*
Yes
No
If yes, please state what
Are you registered disabled?
*
Yes
No
Do you identify as the gender which you were given at birth?
*
Yes
No
Please select how you identify.
*
Male
Female
Other
Prefer not to say
Are you a carer?
*
Yes
No
