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Which service are you referring to?*
Unfortunately referrals for our Post Abuse Support Services are currently closed, until further notice.
Referrals are now closed, due to current waiting times
13 -18 years, with a high risk of offending, or a history of involvement in the criminal justice system
OR
13 - 24 years, experiencing mental health difficulties*
Unfortunately, your referral has not been successful as it does not meet our eligibility.
Who is making this referral?*
Service User Details
First Name*
Surname*
Address line 1*
Address line 2
Address line 3
Town*
Postcode*
Is it safe to post to this address?
Mobile/Landline Telephone No.
Is it safe to Call / Leave Voicemails / Text this number?
Alternative Telephone No.
Primary Email Address
Contact Instructions*
Date of Birth*
Gender*
Ethnicity*
Do you/does the person being referred speak English?*
Referrer Details
Are there any active issues and risks? For example: mental health concerns.*
If yes, please provide details
Does this person pose a risk to themselves or others by violence or injury?*
Are there any issues with a GROW worker lone working with the service user?*
Are there any issues with family/relationships/ friendships that may affect the worker?*
Are there any issues about the home environment that may affect the worker?*
Are there any other issues we need to know about that may affect the worker?*
Reasons for referral and what support is needed*
Process for Partnership Support, including referral agency attendance at the first meeting (a referral will not be processed if this box is not completed): Please indicate here how you see your continued support*
Name & contact details/department of agency (Of any non-referring agencies)
Name of worker/contact (Of any non-referring agencies)
Length of time working with service user (Of any non-referring agencies)
Referrer Name*
Referrer Address*
Referrer Postcode*
Referrer contact number
Referrer Email address*