Inspired by Jesus' example, we create supportive, inclusive and energising communities where all young people can truly belong, contribute and thrive.
loading...
Housing referrals
Submit a referral for accommodation for someone you know
Contact
Monthly giving
We rely on monthly donations to sustain our work
Donate
Resident Zone
If you're a resident at YMCA Exeter use this zone to find useful information
Read more
Our mission and ethos
Find out more about us!
Read on
Latest news
Find out what we're up to and sign up for our newsletter
Follow the link
[contact-form-7 id="14351" title="CWP referral"]
<div role="form" class="wpcf7" id="wpcf7-f14351-o1" lang="en-GB" dir="ltr">
<div class="screen-reader-response" role="alert" aria-live="polite"></div>
<form action="/#wpcf7-f14351-o1" method="post" class="wpcf7-form init" novalidate="novalidate">
<div style="display: none;">
<input type="hidden" name="_wpcf7" value="14351" />
<input type="hidden" name="_wpcf7_version" value="5.2.2" />
<input type="hidden" name="_wpcf7_locale" value="en_GB" />
<input type="hidden" name="_wpcf7_unit_tag" value="wpcf7-f14351-o1" />
<input type="hidden" name="_wpcf7_container_post" value="0" />
<input type="hidden" name="_wpcf7_posted_data_hash" value="" />
<input type="hidden" name="_wpcf7cf_hidden_group_fields" value="" />
<input type="hidden" name="_wpcf7cf_hidden_groups" value="" />
<input type="hidden" name="_wpcf7cf_visible_groups" value="" />
<input type="hidden" name="_wpcf7cf_repeaters" value="[]" />
<input type="hidden" name="_wpcf7cf_steps" value="{}" />
<input type="hidden" name="_wpcf7cf_options" value="{"form_id":14351,"conditions":[],"settings":{"animation":"yes","animation_intime":200,"animation_outtime":200,"conditions_ui":"normal","notice_dismissed":false}}" />
<input type="hidden" name="_wpcf7_recaptcha_response" value="" />
</div>
<p><label> Your name (required)<br />
<span class="wpcf7-form-control-wrap your-name"><input type="text" name="your-name" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></p>
<p><label> Date of birth (required)<br />
<span class="wpcf7-form-control-wrap your-dob"><input type="text" name="your-dob" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></p>
<p><label> Address (required)<br />
<span class="wpcf7-form-control-wrap your-address"><input type="text" name="your-address" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></p>
<p><label> Postcode (required)<br />
<span class="wpcf7-form-control-wrap your-postcode"><input type="text" name="your-postcode" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" /></span> </label></p>
<p><label> Mood scale: Please rate how you are currently feeling, 1 = least intense, 10 = most intense. The answers to these questions will help us complete your assessment.</p>
<p><label> Sad*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Sad" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Sad"><input type="hidden" name="Sad" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> Worried*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Worried" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Worried"><input type="hidden" name="Worried" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> Happy*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Happy" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Happy"><input type="hidden" name="Happy" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> Panicked*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Panicked" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Panicked"><input type="hidden" name="Panicked" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> Angry*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Angry" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Angry"><input type="hidden" name="Angry" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> Low*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Low" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Low"><input type="hidden" name="Low" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> Calm*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Low" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Low"><input type="hidden" name="Low" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> What would you like to change about the way you are feeling? For example, if you had a magic wand that could get rid of this feeling, how would your life be different?*<br />
<span class="wpcf7-form-control-wrap Whatwouldyouchange"><textarea name="Whatwouldyouchange" cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required" aria-required="true" aria-invalid="false"></textarea></span></p>
<p><label> How safe do you feel?<br />
1(not safe) 10(very safe)</p>
<p><label> From yourself?*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Fromyourself" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Fromyourself"><input type="hidden" name="Fromyourself" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> From others?*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Fromothers" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Fromothers"><input type="hidden" name="Fromothers" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> Overall?*<br />
<div class=ocrscf_rainbow-slider type="hidden" name="Overall" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable"><span class="wpcf7-form-control-wrap Overall"><input type="hidden" name="Overall" value="1" class="wpcf7-form-control wpcf7-rangeslider wpcf7-validates-as-rangeslider occf7rs-slider" readonly="readonly" step="1" min="1" max="10" prefixpos="left" slidershow="single" slider_style="rainbow" rangeshow="enable" data-formulas="" /></span></div></p>
<p><label> Your phone number*<br />
<span class="wpcf7-form-control-wrap Phonenumber"><input type="tel" name="Phonenumber" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel" aria-required="true" aria-invalid="false" /></span></p>
<p><label> Your email address<br />
<span class="wpcf7-form-control-wrap Emailaddress"><input type="email" name="Emailaddress" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email" aria-invalid="false" /></span></p>
<p><label> What is your preferred way for us to contact you? e.g. phone call, email<br />
<span class="wpcf7-form-control-wrap Whatisyourpreferredwayforustocontactyouegphonecallemail"><input type="text" name="Whatisyourpreferredwayforustocontactyoue.g.phonecallemail" value="" size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" /></span></p>
<p><label> Thank you for taking the time to complete this form. Please press submit so that we can begin your assessment.</p>
<p><input type="submit" value="Submit your form" class="wpcf7-form-control wpcf7-submit" /></p>
<div class="wpcf7-response-output" role="alert" aria-hidden="true"></div></form></div>
YMCA Exeter & Cookies
This site uses cookies. Not the delicious kind; the computer kind. You can find out more info about this by clicking: Find out more
