Youth Talk Group Counselling Referral Form Question Title * 1. What Group are you interested in? Creative Group (for 13 - 16 years) - based St Albans Thursday Evening Therapy Group (16 - 25 years) - based Harpenden Next Steps (16 years +) - based Harpenden Question Title * 2. First name Question Title * 3. Surname Question Title * 4. Date of birth Question Title * 5. Phone number Question Title * 6. Email address Question Title * 7. Gender Male Female Other Prefer not to say Question Title * 8. Ethnicity White - British White - Irish White - Any other white background Mixed - White and Black Carribean Mixed - White and Black African Mixed - White and Asian Mixed - Any other mixed background Asian or Asian British - Indian Asian or Asian British - Bangladeshi Asian or Asian British - Any other Asian background Black or Black British - Carribean Black or Black British - African Black or Black British - Any other Black background Other Ethnic Groups - Chinese Other Ethnic Groups - Any other ethnic background Not Stated Not known Question Title * 9. sexuality Heterosexual Bisexual Lesbian or Gay Other/unsure Question Title * 10. Religious beliefs Question Title * 11. Address Address Address 2 City/Town County Post Code Question Title * 12. School/College/Work details: Question Title * 13. GP Practice Name Question Title * 14. In your own words why do you wish to come to Youth Talk? Question Title * 15. Have you been to Youth Talk before? Yes No Question Title * 16. When is the best time and method to contact you? Thank you for registering your interest. Someone will contact you soon - if you wish to contact us you can do this by phone 01727 868684 or email info@youthtalk.org.uk Done