CYP Referral Form for Professionals

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Please only use this form if you have been sent the link following a discussion with one of our staff. Referral pathways are only open for specific, limited services at the moment.

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

You can use the form below to refer children and young people that you are working with for support with their experience of domestic violence and 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 
• 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 
• Children and young people who are not currently in crisis or at risk.
Children and Young People not currently in crisis or at risk 
• Parents/carers who consent to being contacted by us to discuss their child or young person’s support options in relation to their experience of domestic violence and abuse specifically.
Parental consent 
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 

Other organisations

Parent/Carer Details

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

Child or Young Person's Details

CYP Date of Birth
Is address different for CYP?
CYP Address (if different from Parent/Carer)
Is GP address different form CYP?
GP Name and Address (if different from Parent/Carer)

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

Sex/Gender

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

Sexual Orientation

Disabilities

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

How are past experiences of domestic abuse impacting the child or young person on a day to day basis? 

Current suitability for CYP and Family intervention:

Are there current criminal court proceedings? 
Are there currently any family court proceedings? 

What is the current contact between the CYP and alleged perpetrator?

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

Thank you for completing this referral.