CYP Referral Form for Parents and Guardians

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

You can use the form below to refer children and young people for 1-1 therapy 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 living in Brighton and Hove

I confirm that this Child or Young Person lives in Brighton and Hove

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

Experience of domestic abuse which is noticeably impacting the child/young person day-to-day

I confirm that this Child or Young Person has experienced domestic abuse, and it is noticeably impacting them on a day-to-day basis

• Children and young people who are not currently in crisis or at risk.

Children and Young People not currently in crisis or at risk (for example, self-harming, still living with the person causing harm)

I confirm that this Child or Young Person is not currently in crisis or at risk

GDPR and Consent

All information is confidential and stored securely on the RISE servers. Information is only shared with third parties with the explicit consent of the person being referred or if there is a risk of significant harm/safeguarding concerns

Please tick this box to confirm that you accept the above

Person making referral:

Relationship to Child or Young Person:

Who is the best person to speak to about this referral, and what are their contact details?

Parent/Carer Details

Parent/Carer First Name

Parent/Carer Last Name

Parent/Carer Address

Address 1

Address 2

Town/City

Post Code

Parent/Carer Date of Birth

Parent/Carer Contact Number

Parent/Carer Email

Is it safe to (tick all that apply):

Leave a voicemail

Send a text

Contact via email

Send post

Parent/Carer GP Details

GP and Surgery Name

Street Address

Town/City

Post Code

Child or Young Person's Details

CYP First Name

CYP Last Name

CYP Date of Birth

Is address different for CYP?

Please tick if CYP has a different address to Parent/Carer

CYP Address (if different from Parent/Carer)

Street Address

Town/City

Post Code

Is GP address different form CYP?

Please tick if CYP has different GP to Parent/Carer

GP Name and Address (if different from Parent/Carer)

GP and Surgery Names

Street Address

Town/City

Post Code

Which nursery/school does your child/young person currently attend?

WARNING - are you a person at risk?

CYP Referral Form for Parents and Guardians

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

You can use the form below to refer children and young people for 1-1 therapy 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.

• Children and young people who are not currently in crisis or at risk.

GDPR and Consent

Parent/Carer Details

Child or Young Person's Details

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

Sex/Gender

Sexual Orientation

Disabilities

Does your CYP have any of the following accessibility requirements?

Mental Health History and Diagnoses

Your CYP's Ethnicity

Other organisations

Please tell us the reason for this referral

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

Thank you for completing this referral.