My referral

Guidance notes

This form is to help us understand your current situation and how we may be able to support you.

We will keep all information in line with our confidentiality policies.

Our programme accepts self-referrals and supported self-referrals (in other words, if you are making this on behalf of someone else, they will be completing this form with you).

What to do next

I am completing this form about myself

If you need help with completing the form, or if you have any questions, please call 0344 515 1615. Also, please tell us about any services who you are working with already. We won’t contact anyone without your permission.


I am being supported to make a self-referral by someone else

Please ensure that you put the details of the person supporting you on the form so that we can contact you both to discuss the referral.


If I am not with the person I’m referring

Please call the engagement team first on 0344 515 1615 to discuss. We can talk about the best way of making a referral with you.

About me

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Best ways to get in touch

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More about me

Please tell us as much as you can in this section

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Inspiring Change Manchester works with people aged 18 and over who are not actively engaged with existing services, and are experiencing three or more of the following:

  • Homelessness or unsuitable and unsustainable accommodation
  • Problematic drug and/or alcohol use
  • Mental health or emotional well-being problems
  • Offending behaviour or involvement in the criminal justice system.

Please say how things have been for you in the following areas:

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Anyone who is supporting me at the moment

This could be a friend, relative, your GP or other organisation

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If you have been supported by someone to complete this form, please put their details below

Client declaration

We would like to be able to support you with this referral therefore we ask for your permission to share the information on this form with our engagement team and ICM partners. This will only be used to enable us to understand your situation and see what support would suit you best.