Referral Form

Are you a Young Person or an Adult?

Are you one of our referral partner organisations or other connected adult?

Which referral pathway do you represent?

Have you given out an emotional support pack (Calm & Care Pack)

Yes

REFERRER'S DETAILS

First Name(s)

Surname

Mobile Number

Address line 1

Address line 2

Town

Postcode

YOUNG PERSON'S DETAILS

First Name(s)

Surname

Date of Birth

Gender

Mobile Number

Email Address

Address line 1

Address line 2

Town

Postcode

Have you received an emotional support pack (Calm & Care Pack)

Yes

Please tell us why you are getting in touch with us?

Is it something in School, Online, Home or Somewhere else?

Have you told anyone about what is happening? For example a Teacher or a Friend?

Yes

CONNECTED ADULT DETAILS

First Name(s)

Name

Mobile Telephone No.

Primary Email Address

Address line 1

Address line 2

Address line 3

Town

County

Postcode

Duplicator

VICTIM OF CRIME

Murder or Manslaughter (homicide)

Yes

Attempted Murder

Yes

Knife Crime

Yes

Assault

Yes

Domestic Abuse

Yes

Sexual Abuse/Assault

Yes

Stalking

Yes

Online Grooming/Exploitation

Yes

Child Sexual Exploitation (CSE)

Yes

Child abuse, neglect or cruelty

Yes

Drug-related (eg. County Lines)

Yes

Theft

Yes

Burglary

Yes

Robbery

Yes

Bullying or Hate Crime

Yes

Anti-Social Behaviour

Yes

Other

Yes

WITNESS OF A CRIME

Living in a household where a crime has occurred/is occurring, ie domestic abuse, drug taking/dealing

Yes

Been at a venue where you saw a crime happen, eg. spiking a drink in a pub or club

Yes

Seen a crime take place at school, eg. physical violence or severe bullying

Yes

Other

Yes

Multiple vehicle road accident

Yes

House or building fire

Yes

Other major Incident

Yes

Likely to be at risk of being involved in a crime

Vulnerable to becoming a drug courier

Yes

Being co-erced into criminal behaviour either by another child or young person or by an adult

Yes

Other

Yes

Overview

Please give a brief overview to explain the circumstances behind the box(s) you ticked.

Where did the activity take place that caused harm to the child or young person or which Police Force area is dealing?

Important! By continuing you are consenting to the following…

you consent to Three Nines Children's charity collecting adn securely storing the personal information you provide. Your information will be used only so that our specialist staff and approved contractors can provide you with our confidential, trauma-informed support services. the bottom of tgh

Your data will be stored securely on our confidential database and will not be shared with anyone outside our organisation unless we are requird to do so by law or where safeguarding concerns means we must act to keep someone safe.

We only keep the information we need, and records are securely deleted after seven years. You can withdraw your consent or ask about the information we hold about you at any time. For more details, please see our Privacy Notice.

Important! By continuing you are consenting to the following…

I agree that Three Nines Children's Charity can collect and store the information I share so they can support me.

Only trained staff and trusted helpers working with the charity will see my information and only so they can help me. My information will be kept safely and privately.

We will only keep the information we need and will normally delete it after seven years.

If I have questions about my informtion or want to change my mind, I can ask the charity at any time.

Your Safety Comes First

What you tell us is private. However, if we believe that you or someone else is in serious danger or at risk of harm, we may ned to share information with people who can help keep you safe (such as safeguarding professionals or the police). If possible, we will always to try to talk to you about this first.

For more information about how we use and protect your information, please see our Privacy Notice or contact us at mail@threenines.org.uk.