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Self Referral for Young People or Parents/Carers

Self Referral for Young People or Parents/Carers

We have a shorter self referral form for use by Young People or their parents/carers to help make our service is accessible to everybody.

You can access the self-referral form by clicking here, or scanning the QR code below with a smart phone.




If you need any further information about our service or submitting a referral, please contact our friendly Business Support team via the details below. We can also provide the self-referral form in paper or in alternative languages. 

  • Email:
  • Tel: Heather (Mon-Fri) 07866 062740
  • Tel: Marissa (Tue-Fri) 07866 062732
  • Tel: Mark (Mon-Wed) 07866 062763

We want to make our service as accessible to children and young people as we can although please note that Changing Lives is not a crisis support service. If you need urgent support and live in Derbyshire telephone 'Call Derbyshire' on 01629 533190, alternatively if you live in Derby City telephone 'Care Line' on 01332 786968. For other services that may be able to help if you are in crisis, please see here. Alternatively you may find. Alternatively you may find our Useful Links page helpful.



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