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Online Referal Form
Referral to Doorway 16 to 25 Service
ASH Mental Health Wellbeing service
Tom’s Place service
Young Person’s Service
Doorway has a Young Person’s Service for young people aged 16-18 years old.
Disabled access required for assessment:
Male / Female
Type of accommodation occupied by Young Person prior to being referred to Doorway
Local Authority tenant
H Assoc tenant
Staying with friends
Other temp accommodation
Direct access hostel
Living with family
Other (please specify)
Has the applicant had any previous contact with Doorway?
Referring Agency Details
Are you aware of any other professional organisations that are working or have worked with the client?
Financial Information – Please tick income source of applicant:
Has the applicant any current or previous convictions?
Is the applicant currently or have they ever been on probation?
Is the applicant currently or have they ever been in care? (eg. Foster Care)
Please advise us of the names of any Social Worker or Probation Officer if applicable:
Equal Opportunities Monitoring:
This section has no effect on the referral process or subsequent interviews
What is the young persons Ethnic Origin?
Declaration (to be completed by the applicant)
I consent to the disclosure of information to Doorway and understand that Doorway might seek further information from my referring agency or other outside bodies as required.
Declaration (to be completed by the referring agency)
All of the above information is true, to the best of my knowledge.
Charity No: 1067127 Patron Ken Loach
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