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Coronavirus update

Due to recent government advice to work from home, our office is closed until further notice. Our helpdesk line has been redirected and will be extremely busy. We ask that you contact us by completing our online referral form.

Always call 999 if it's an emergency or you're in immediate danger.

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.

Section 1: Referrer

Details of the person making the referral

1. Name

2. Organisation

3. Position

4. Email address

5. Telephone number

Section 2: Young person

Details of the young person being referred

1. Name

2. Date of birth

3. Gender

Male

Female

Non-binary

Transgender

4. Ethnicity

5. Address

6. Telephone number

Is this number safe to call?

Yes

Is this number safe to text?

Yes

7. Email address

Is it safe to email?

Yes

Section 3: School/college details

1. School/college

2. Key school/college contact

3. School/college contact telephone number

4. School/college contact email address

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

Yes

N/A

Section 4: Disabilities and additional support requirements

1. Does the young person experience any of the following? Please tick all that apply.

Mobility needs

Mental health needs

Physical health needs

Hearing impairment

Visual impairment

Learning disabilities/difficulties

Allergies

Other (please specify below)

If you have checked any of the boxes above, please provide details:

2. Does the young person need any additional support for sessions (Group/1:1)? Eg help with reading and writing.

Yes

If yes, please explain:

Section 5: What the young person has experienced

1. What type of abuse is the young person experiencing? Please tick all that apply.

Abuse in their current relationship

Abuse from an ex-partner

Abuse from a family member

Adversely affected by domestic abuse in the home

The young person is demonstrating abusive behaviours

2. Please give a brief background history of the abuse. This should include how long the abuse has been happening, the types of abuse (eg emotional, physical, sexual) and how this has impacted on the young person. Where the abuse is historical please include how long ago it took place and the young person’s understanding of what happened.

3. What outcomes do you hope will be achieved through our support?

4. What support is the young person hoping for from our service? What would they like our support to help them with?

5. What are the young person's strengths? How can they be built on as part of our intervention?

6. Please give details about the young person's interactions with peers and adults. Are there any triggers that we should be aware of? Is the young person known to be violent or aggressive?

7. Is the young person dependent on anything, such as drugs, alcohol or solvents?

8. Please give details of any known risks (to either the young person, any other vulnerable person or a professional) in contacting the young person and/or their family:

9. Does the young person have a child protection plan in place or involvement with Social Services?

Yes

If you answered yes, please tick all that apply:

Early Help Assessment

CiN plan

CP plan

LAC plan

10. Please give the name and contact details of the social worker and any other professionals working with the young person (eg Families First, mental health, substance worker, youth offending team):

11. Is the family involved or been involved with MARAC (Multi Agency Risk Assessment Conference)?

Yes

12. Can the young person safely attend a session and keep the service and venue confidential from any abusive party?

Yes

Section 6: Person causing harm

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

1. Name

2. Date of birth

3. Gender

Male

Female

Non-binary

Transgender

4. Address

5. School/college (if applicable)

6. Are there any orders in place which prevent contact with the young person? If so, please provide details:

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

1. Name

2. Address

3. Telephone number

Is this number safe to call?

Yes

Is this number safe to text?

Yes

4. Email address

Is it safe to email?

Yes

5. Relationship

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.

1. Do not share information with these agencies:

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

Yes

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:

Yes

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:

Yes

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:

Yes

Please explain:

Section 11: What to do next

1. Has a risk assessment been completed?

Yes

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 street.glos@gsg.cjsm.net or via EGRESS to street@wmwa.org.uk.

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 marac@gloucestershire.pnn.police.uk.

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.

Please email me a copy of this referral

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

Champion Network Resource Centre