Refferal Individual | Proud To Be Me CIC Website

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We accept referrals from schools, colleges and professionals supporting young people. Please complete the form below. A member of our team will respond within 2–3 working days.

REFERRER DETAILS

Referrer Name

Job Title

Organisation Name

Email

Phone

YOUNG PERSON DETAILS

Full Name

Age / Date of Birth

Gender (optional)

Preferred Pronouns (optional)

EDUCATION / CONTEXT

School / College Name

Current Status

REFERRAL DETAILS

Reason for referral

Primary Needs

Behavioural challenges

Mental health / wellbeing

Confidence / self-esteem

Risk of exploitation

At risk of exclusion

Other (please specify)

RISK & SAFEGUARDING

Risk Level

Is this referral urgent?

Any known safeguarding concerns?

CURRENT SUPPORT

Is the young person receiving other support?

If Yes

Social worker

SENCO / school support

Youth offending team

Other

FUNDING (Optional)

Is funding already identified?

If yes

AVAILABILITY

Preferred days / times

Any restrictions

DOCUMENT UPLOAD

Upload referral form / EHCP / supporting documents

CONSENT

Consent*

Thank you for your referral. A member of our team will review the information and contact you shortly.

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The Loft, Facework,

MakerSpace, Queens Road,

London, England,

SE14 5HD

Proud to Be Me CIC is a Community Interest Company registered in England and Wales. Company No: 15018054

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