CYP Referral Form for Parents and Guardians

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.

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.

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

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

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

Day

Month

Year

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 *

Day *

Month *

Year *

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

CYP Address (if different from Parent/Carer)

Street Address

Town/City

Post Code

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? *

Please tell us the reason for this referral

Details of the referral (Please tell us how your Child or Young Person has been impacted by domestic abuse. Please include any presenting issues/symptoms and safeguarding or risk issues): *

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

Are there current criminal court proceedings? *

Yes

If 'yes', please give details:

Are there currently any family court proceedings? *

Yes

If yes, please specify e.g. child custody, child protection, divorce

What is the current contact between the CYP and alleged perpetrator? (If none, when was the last contact?) *

Do you wish to receive a copy of this referral form to your email inbox? *

Yes

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

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

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.

CYP Referral Form for Parents and Guardians

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.

• 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.