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STREET referral form

Please complete all sections of this form as fully as possible. Any incomplete information may result in a delay to the referral being processed.

Please be aware that we are not currently running face-to-face support groups for young people, and we are unable to offer face-to-face appointments due to coronavirus restrictions and government guidance.

You can use this form to refer to our usual services, but please be aware that we may only be able to offer ‘keeping in touch’ or remote support to young people at this time until our usual groups and face-to-face appointments resume.

Thank you for your understanding and patience. We hope to resume our support packages as soon as it is safe to do so.

Section 1: Referrer

Details of the person making the referral

Section 2: Young person

Details of the young person being referred

3. Gender
Is this number safe to call?
Is this number safe to text?
Is it safe to email?

Section 3: School/college details

5. Is the school/college aware of this referral?

Section 4: Disabilities and additional support requirements

1. Does the young person experience any of the following? Please tick all that apply.
2. Does the young person need any additional support for sessions (Group/1:1)? Eg help with reading and writing.

Section 5: What the young person has experienced

1. What type of abuse is the young person experiencing? Please tick all that apply.
9. Does the young person have a child protection plan in place or involvement with Social Services?
If you answered yes, please tick all that apply:
11. Is the family involved or been involved with MARAC (Multi Agency Risk Assessment Conference)?
12. Can the young person safely attend a session and keep the service and venue confidential from any abusive party?

Section 6: Person causing harm

If you do not have this information please continue to the next section.

3. Gender

Section 7: Parent/guardian details (the next of kin if different)

Is this number safe to call?
Is this number safe to text?
Is it safe to email?

Section 8: Confidentiality and information sharing

Please ensure this has been discussed with both the young person and parent/guardian:

STREET is a confidential service. However if a disclosure is made that you or someone else is at risk of or suffering significant harm or that a crime has or will be committed, STREET staff have a duty to pass this information to the relevant agencies. Where it is safe to do so, STREET staff will contact you and/or your parent guardian prior to sharing this information.

STREET may speak to other agencies regarding the support that you and/or your young person is receiving in order to gather more information or to pass on information where there is a legitimate reason for so doing. Please state below if there are any agencies you do not give us permission to share information with.

2. Has confidentiality and information sharing been explained to the young person and their/parent carer?

Section 9: Consent from the young person

STREET Gloucestershire is a confidential service although if there were any safeguarding concerns this information would be shared appropriately.

STREET Gloucestershire is only able to work with young people and share information where the young people themselves have explicitly consented to do so. Referrers should ensure that the young person is aware of the service to which they are being referred and why they are being referred.

1. The young person has capacity and has consented to this referral:

Section 10: Consent from the young person’s parent/person with parental responsibility

For young people 15 years and under, parental consent should always be sought.

Whilst parental consent is not essential for young people aged 16 years and over, STREET prefers to work with young people where their parent/person with parental responsibility has consented for that work and referrers are asked to seek consent from parents where it is safe to do so.

1. The young person’s parent/person with parental responsibility has consented to this referral:

Consent not sought

We realise that it may be difficult in circumstances where the main care giver is experiencing domestic abuse for this consent to obtained and that there may be occasions when it is not safe to seek that consent. Where consent has not been obtained, please indicate below, and include an explanation.

2. The young person’s parent/person with parental responsibility has not been contacted for their consent at this time but the young person can consent independently:

Section 11: What to do next

1. Has a risk assessment been completed?

The DASH risk assessment is to be completed with the young person where there has been any form of relationship abuse occurring within the last 3 months and where they have recently split from or rekindled an abusive relationship. This form can be used with young people aged 13+ and measures the risk posed to the young person and will ensure that STREET is able to design the most effective support package for them. For young people aged 16+, this form is also your MARAC referral – please see below.

Young People's DASH Form

Young People's DASH Completion Guide

Please send the assessment to or via EGRESS to

If you are concerned that the young person you are referring is in immediate danger, please refer to the information below:

If you feel there is an immediate threat of harm or a risk to life then dial 999 before making this referral.

If the young person is 16 or over and you believe they are at high risk of serious harm through domestic abuse, then a referral to MARAC (Multi Agency Risk Assessment Conference) must be made. This is achieved by completing the Young Person’s DASH (above) and sending it to

A young person experiencing domestic and/or relationship abuse is a safeguarding concern and making this referral does not end your safeguarding responsibilities. If a young person, at any age, is in danger, or you are concerned that they are at risk of serious harm then please call the Multi-agency Safeguarding Hub on 01452 426565. Online safeguarding referral forms can be found here

Request a copy of this referral

Please tick the box below if you would like us to send you a copy of this referral via email once it has been processed.

STREET is delivered in partnership with West Mercia Women's Aid.

West Mercia Women's Aid logo