Future SELPH: self-referral form

Future SELPH supports and promotes the well-being of young adults (aged 16-25) by equipping and empowering them to overcome life’s challenges.

Please note, participants must be actively involved in this self-referral process, although a parent, carer of professional can support them in this.
Full Name
Phone Number

HomeMobile
Date of Birth

DayMonthYear
Ethnicity
Gender
Pronoun
Employment status

Other
Email
example@example.com
Address

Street Address

Street Address Line 2

Town/CityCounty

Post code
Where did you hear about Selph?

Other
What would you like to gain from Selph?
Have you received mental health support from any other service?
If so, which service or agency?
If you are currently working with any professional around your wellbeing, what is their name, agency and contact details?
What is your initial preferred method of contact?

Other
Do you have a preference to who will initially contact you?
PERSONAL DATA & PRIVACY

We take our responsibility to look after your personal data seriously. If you want to know more about how we do that you can read our Privacy Policy on our website at youth-association.org/privacy-policy.
YOUR RIGHT TO WITHDRAW CONSENT

You have the right to change your mind later and withdraw your consent. Contact us at data@youth-association.org or call us on 01924 333400 and we will remove your images where that is possible. If you withdraw your consent we will stop using the photos, videos and audio content for future purposes but we may not be able to remove anything already in the public domain, (like on social media, etc.)
I consent to The Youth Association storing my details for the purposes described in this form.
I acknowledge that this form is powered by 'JotForm', a platform compliant with GDPR - the standard for consumer data protection rights.
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Future SELPH supports and promotes the well-being of young adults (aged 16-25) by equipping and empowering them to overcome life’s challenges.

PERSONAL DATA & PRIVACY

YOUR RIGHT TO WITHDRAW CONSENT