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Online Self-Referral Form - Children & Young People 12 and older

About this referral

If you need to speak to someone urgently, please consider the following contacts including the mental health crisis team: (0808 196 3779)

It’s okay to not feel okay. Things can seem overwhelming. For example, you may:

  • feel sad or hopeless
  • have problems with your family, friends or at school
  • hurt yourself or have thoughts about hurting yourself
  • feel anxious and scared
  • have problems with eating and food
  • have trouble talking or sleeping
  • feel angry or are struggling to control your behaviour or temper
  • find it hard to concentrate or get on with friends
  • have to check or repeat things, or worry about germs
  • do not like yourself or have low self-confidence
  • have other things on your mind that you find difficult.

The Be U Notts Service is here to support you if you struggle with your feelings.

Please fill in your details below and someone from the Be U Notts Service will get in touch to discuss how we can help you. 

Or you can phone us: 0115 708 0008

So we can give you accurate and appropriate advice, we sometimes need to share the details you have provided with others such as your GP, social worker or any other services, relevant to the support we provide to you.

By accepting this, you are giving consent for your personal information to be shared with those relevant professionals. The sharing of your details is carried out in compliance with the Data Protection Act 2018. For more information on Data Protection visit https://www.gov.uk/data-protection

Customer declaration: 

  • I give consent for the Be U Notts Service to share my details with relevant professionals /organisations to help the Be U Notts Service to give me accurate and appropriate support.
  • Once given, I may withdraw consent at any time, by writing to the Be U Notts Service Manager and asking for my referral to be cancelled. This will mean I will be discharged from the service, notification sent to my referrer if relevant and my referral will be closed on our secure patient database.
  • I agree that information provided will be stored on a secure Be U Notts database for a minimum of 2 years and to be used anonymously for monitoring purposes.

Questions marked as * are required