Family Respect Referrals

Privacy notice:
Your data will be held securely by YMCA Trinity Group from the date a referral is made to us and up to 12 months from the date we finish working with your family.

From 12 months after we stop working with you and your family your data will be unidentifiable and anonymised and it will only be used within the broader project data to evidence project delivery. This broader project data will be used towards funding opportunities and the development of future services.

You can ask us to stop storing your data at any time and you can do this by contacting us via familyrespect@ymcatrinity.org.uk

We are not able to remove your unidentifiable and anonymous data from the broader project data once we begin our work with you and your family.

Does the family consent to the privacy status? You have confirmed that the family understands how YMCA Trinity Group will manage their data*

Does the family consent to YMCA Trinity Group contacting them about the Family Respect programme? By selecting yes, you are confirming that YMCA Trinity Group can make contact with the family about the Family Respect Programme.*

Young person's first name*

Young person's surname*

Interpreter required?*

Young person's date of birth*

Young person's age*

Young person's gender*

Young person's ethnicity*

Does the young person have any physical disabilities?*

Does the young person have any of the following developmental, learning, or mental health difficulties?

Synthasesia

Yes

Tourette's syndrome

Yes

Sensory Processing Disorder (SPD)

Yes

Learning Disorders

Yes

Pathological Demand Avoidance (PDA)

Yes

Dyslexia, Dyscalculia, Dysgraphia, Dyspraxia, Hyperlexia,

Yes

Bipolar Disorder

Yes

Depression

Yes

Oppositional Defiant Disorder

Yes

Anxiety Disorder

Yes

Conduct Disorder

Yes

Global Development Delay

Yes

Fetal Alcohol Syndrome

Yes

Attention Deficit Hyperactivity Disorder (ADHD)

Yes

Autism Spectrum Disorder (ASD)

Yes

Young person's address:

Address Line 1*

Address Line 2*

Address Line 3

Town*

Postcode*

Does the young person display physical abuse?*

Does the young person display sexual abuse?*

Does the young person display economic abuse?*

Does the young person display coercive control?*

Does the young person display violent or threatening behaviour?*

What are you worried about in relation to the abusive behaviours?*

What does the young person think about the referral?*

What is the relationship between the young person and the victim/s?*

Who lives with the young person?

Grandfather

Yes

Grandmother

Yes

More than 2 siblings

Yes

2 Siblings

Yes

1 Sibling

Yes

Step-Father

Yes

Step-Mother

Yes

Father

Yes

Mother

Yes

Other

Full name of parent/carer 1?*

Parent/carer 1 contact telephone number*

Full name of parent/carer 2?*

Parent/carer 2 contact telephone number*

Professional Information

Which service do you work for?*

Your professional email address*

Your professional contact telephone number*

First Case Date

Privacy notice:
Your data will be held securely by YMCA Trinity Group from the date a referral is made to us and up to 12 months from the date we finish working with your family.

You can ask us to stop storing your data at any time and you can do this by contacting us via familyrespect@ymcatrinity.org.uk

We are not able to remove your unidentifiable and anonymous data from the broader project data once we begin our work with you and your family.

You have confirmed that YMCA Trinity Group can make
contact with the family about the Faily Respect programme.