For Office Use: Date Received
Reference No
Referral Form for Children & Young People Support
Note: Counselling Clients should live within Lancashire Boundaries. We cover Preston, West Lancashire and Chorley for ISVA support.
For completion by Referrer
Which Service is required?
Delete as appropriate
ISVA / Counselling / Both
Referred by (name)
Agency
Contact No(s)
Email address
NOTE: To avoid any delay in processing the referral, please read our referral criteria which can be found on the back of this
referral form. If you are happy that the referral meets these criteria, please complete all sections of the referral form.
Young Person’s Contact & Personal Information
*Client
First Name
*Client
Last Name
Title
Known as
*Age:
Date of Birth
Ethnic Origin
Language
Gender
Male
Female
Street Address
Transgender Male to Female
DD/MM/YY
Transgender Female to Male
Home Tel:
*Town
*Mobile Tel No.
*Post Code
*Email Address
Parent or Carer Contact
Details
Please indicate
who has parental
responsibility
Post
*Please tick the
communication method
we CAN use
Phonecall
Text
*What is the preferred method of communication?
Phone / Letter / Text / Voicemail
Voicemail
Client Disability Information
The following information will help us to ensure that our service is meeting the needs and is accessible to the whole
community.
Learning or physical
disability/health issues?
Yes / No / Rather not say
Please give us
some information
*Does your client have
any special requirements
in order to ttend/receive
a service from us?
Yes / No
Please give
details
Significant Adults & Young People
Please list adults first followed by children
Name
Relationship to Child
Gender
Age
Male
Female
Transgender
Male
Female
Transgender
Male
Female
Transgender
Male
Female
Transgender
Male
Female
Transgender
Male
Female
Transgender
Male
Female
Transgender
Male
Female
Transgender
Male
Female
Transgender
*Safeguarding.
Is the young person subject to a Child Protection Plan or Child in
Need Plan?
Yes / No / Unknown
Please provide details
Reason for the Referral
Has the young person been made aware of this referral?
Please include details of the abuse, and how this has affected the child or young person Include any other relevant information
Date of Incident
Perpetrator relationship to client?
Age of child at time of abuse
Is the young person supported and in a safe place
2
When completed, please return to:
Trust House Lancashire, PO Box 1355, Preston, PR2 OUE OR [email protected]. We also have a secure
email [email protected] Please note you will need CJSM email account to use this secure email.
Offence Information
*Has the incident(s) been reported to
the Police?
Yes / No / Unknown
Is there a current Police investigation?
Yes / No / Unknown
Please provide details
*If yes, please provide Crime Number
Contact Details (if different to
front page)
Name of Officer in case
Has the offender been arrested?
Yes / No / Unknown
IS the Offender on Police bail?
Yes / No / Unknown
Has the Offender been charged
Yes / No / Unknown
Is the Offender on Court Bail?
Yes / No / Unknown
Date abuse reported
Who reported the abuse?
Are there any outstanding investigations or court proceedings?
If yes please provide details
Did the child/ young person make a statement / undertake an ABE
interview
Agency Involvement - Please give details of any other agencies involved. (if known)
Agency
Contact
Email
Telephone
Contact Name
Email
Telephone
Email
Telephone
Education
School or College(s) Attended
School Year
Is the school aware of the situation?
Any issues regarding school?
Any other education professionals involved?
*Does the client have any convictions for either sexual or violent
offences?
Yes / No / Unknown
3
When completed, please return to:
Trust House Lancashire, PO Box 1355, Preston, PR2 OUE OR [email protected]. We also have a secure
email [email protected] Please note you will need CJSM email account to use this secure email.
Please give details here
Please call us on 01772 825 288 if you have any queries.
Criteria for Referral to the Service:
o Children and Young People 4 -17 years who have been affected by sexual abuse or rape and where there has been an agency
investigation.
o We offer counselling to children and young people who may or may not be going through the criminal justice process.
o ISVA work is focused on cases with open police or court procedures.
o The Child / Young person needs to be living in a safe place
o A Child or Young person needs to be ready to engage in the service.
o Younger Children need to be accompanied to the sessions by a trusted adult/ or be available.
o With parental consent older children will generally be seen independently.
o Please do not assume that all referrals will be accepted by Trust House Lancashire, we will assess the child / young person’s
suitability from the information that is provided on the referral form and the first initial contact with child / young person
o All information provided will be treated in the strictest confidence.
o If the referral is unable to be accepted by Trust House Lancashire.
4
When completed, please return to:
Trust House Lancashire, PO Box 1355, Preston, PR2 OUE OR [email protected]. We also have a secure
email [email protected] Please note you will need CJSM email account to use this secure email.