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*

Email Address*

Address line 1

Address line 2

Town

Postcode

YOUNG PERSON'S DETAILS

First Name(s)*

Surname*

Date of Birth

Gender

Name (Parent/Carer/Guardian)*

Mobile Number (Parent/Carer/Guardian)*

Email Address (Parent/Carer/Guardian)*

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

Reason for Referral – please choose one. You will be asked for brief details later.

Overview

Please give a brief overview to explain the reason for your referral.

Any additional siblings that also require support can be added below

'In which county did the crime or traumatic incident take place?

Important! By continuing, you are consenting to the following…

You consent to Three Nines Children's Charity collecting and securely storing the personal information you provide. Your information will be used only to enable our specialist staff and approved contractors to provide you with our confidential, trauma-informed support services.

Your data will be stored securely on our confidential database and will not be shared with anyone outside our organisation unless we are required 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 what 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 need 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.