CYP Referral Form for Parents and Guardians

Please note that the child or young person being referred must be aged 18 or under.

Children, Young People's, and Families Referral Form - for PARENTS and GUARDIANS

We have made the difficult decision to close the waiting list for 1-1 therapy, including music therapy in the Children and Young Person’s (CYP) Service from 5pm on Friday 6th November 2023. We are still accepting referrals for CYP group support.

You can use the form below to refer children and young people for group support who have experienced domestic abuse. RISE CYP and Family Service offers support to:

• Children and young people who live in Brighton and Hove.
• Children and young people who have been impacted by some form of domestic violence or abuse in their lives.

Parent/Carer Details

Parent/Carer Address
Parent/Carer Date of Birth
Is it safe to (tick all that apply): *
Parent/Carer GP Details

Child or Young Person's Details

CYP Date of Birth *
CYP Address (if different from Parent/Carer)
GP Name and Address (if different from Parent/Carer)

Please provide us with some more details about the child or young person being referred:


What is your child’s sex assigned at birth?
Do they still identify with that gender?

Sexual Orientation


Does your CYP have any of the following disabilities? (Tick all that apply)

Does your CYP have any of the following accessibility requirements?

Tick all relevant boxes

Mental Health History and Diagnoses

Is your CYP okay communicating in English?
Does your CYP need an interpreter?

Your CYP's Ethnicity

Other organisations

Please tell us the reason for this referral

Current suitability for RISE Children and Young Person's support:

Are there current criminal court proceedings? *
Are there currently any family court proceedings? *
Do you wish to receive a copy of this referral form to your email inbox? *

Thank you for completing this referral.