Skip to main content
User account menu
CiviCRM
Log in
Services
Therapeutic Services
Counselling SPA referral
Counselling victim of crime
SAFE (Sexual abuse program)
Little minds in mind (parent infant program)
Masqueraid (Neurodiversity)
Group work (Please see current groups)
FAB (Disability group)
Children With Disabilites
Communities
Ways to Wellbeing
Domestic abuse recovery support
Ways to Wellbeing plus
Newcastle volunteer support
CAN (young people mentoring support)
For Families - Children North East
Intensive family support
Intensive family support
Be more
Professional Referral Form
Service Required
Please select the service you are referring for. You can find out more about each of our services via the links in the menu on the left.
- Select -
Counselling SPA referral
Little minds in mind (parent infant program)
Masqueraid (Neurodiversity)
FAB (Disability group & other neuro and SEND groups)
Communities all programmes
Can (young people mentoring support & children with disabilities mentoring support)
Intensive family support
Case Type
- Select -
Youth Link and CAN
Little Minds in Mind
Families and Parenting
Counselling
Neuro Case
SAFE Project
Client details
Type of Individual
Parent/Carer
Child
Young Person
First Name
Last Name
Preferred Name
Pronouns
Phone Number
Email
Who is the primary Parent/Carer?
First Name
Last Name
Relationship to Young Person
Parent of
Primary Carer of
Birth Date
Gender
None selected
Female
Male
Transgender
Non-Binary
Gender Fluid
Other
Not known
Sexuality
None selected
Asexual
Bisexual
Gay
Hetrosexual
Lesbian
Pansexual
Questioning
Unsure
Not applicable
Ethnicity
None selected
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed/multiple ethnic background
Asian/Asian British - Indian
Asian/Asian British - Pakistani
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Any other Asian background
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - any other background
Other ethnic group - Arab
Other ethnic group - any other ethnic group
Not stated
British - Afganistani
Disability
Autism
Aspergers
Learning Difficulty
Learning Disability
Long term or life-limiting illness
Mental Health Issues
Multiple Disabilities
Physical disability
Sensory disability
Prefer not to say
Other
Do you/family require any additional support to access our services?
What are the current living arrangements?*
Family
Kinship Care
Independent Living
Supported Living
Foster Care
Adopted
What is the client's first language?
English
Arabic
Bengali
Chinese - Cantonese
Chinese - Mandarin
Czech
Dutch
French
German
Greek
Gujurati
Hindi
Italian
Japanese
Kurdish
Pashto/Pakhto
Persian/Farsi
Panjabi
Polish
Portugese
Romanian
Russian
Spanish
Slovak
Tagalog/Filipino
Turkish
Urdu
Yoruba
Other
Language if other
Is an interpreter required?
Yes
No
How did you hear about Children North east?
Emergency Contact
First Name
Last Name
Phone Number
Street Address
City
State/Province
- None -
Postal Code
Preferred Communication Method(s)
Phone
Email
Letter
Privacy Preferences
Do not email
Do not phone
Do not mail
Referral details
Reasons for referral
Presenting issues 1
Presenting issues 2
Presenting issues 3
Your details
First Name
Last Name
Phone Number
Email
Referrers Organisation
Which organisation do you work for?
Name of organisation
If you are referring on behalf of someone please confirm the person/family are aware the referral is being made.
Yes
No
Please tick here to confirm that you and / or the person/family who you are providing this referral for on behalf of gives consent to the personal information contained in this form being shared with Children NE?
Yes
No
School
Which School/ College/ University do they attend?
Name of school
Which School/ College/ University do you/they attend? (text version)
Is the School/ College/ University aware that this Referral has been made?
Yes
No
GP
Which GP Surgery is the person registered with?
GP Surgery Name
Is the GP aware that this referral has been made?
Yes
No
Are you / is the person/family currently subject to a child protection plan/child in need plan/early help plan?/LAC
Yes
No
Are you a carer?
Yes
No
Which agencies/ professionals are you or been previously been involved with?
Are you currently on a waiting list for an assessment with any other organisation please state which waiting list and what for?
Yes
No
please state which waiting list and what for
Main reason for referral and please provide any other information that you would like to share with us
Additional service questions and supporting documents
Children removed from parents care
Yes
No
Children at risk of being removed
Yes
No
Rehabiltiation support package
Yes
No
Current court proceedings
Yes
No
substance misuse
Yes
No
Parenting concerns
Yes
No
Child protection concerns
Yes
No
SGO support package
Yes
No
Struggling to meet child/rens needs
Yes
No
Neglect
Yes
No
Physical abuse
Yes
No
Sexual abuse
Yes
No
Emotional abuse
Yes
No
Self Harm
Yes
No
Suicidal Ideation
Yes
No
Offending
Yes
No
Addictions
Yes
No
Has there been a suicide attempt in the last 12 weeks?
Yes
No
This is not a diagnostic service. Please tick to confirm this is understood at referral
Yes
No
NEET
Yes
No
Confidence building
Yes
No
Support to attend appointments
Yes
No
Support to access activities
Yes
No
Support with CVs , job applications etc
Yes
No
Crime type:
Child Criminal Exploitation
Child Sexual Abuse / Child Sexual Exploitation
Cyber Crime
Domestic Abuse
Fraud
Hate Crime
Homicide
Modern Slavery
Sexual Violence
Stalking and Harassment
Road Crime
Terrorism
Theft
Violent Crime (with or without injury)
Other
Are you engaged with the criminal justice system?
Yes
No
If not please give details
Crime type:
Sexual Violence
Stalking and Harassment
Other
Are you engaged with the criminal justice system?
Yes
No
If not please give details
Would you require the family support element of SAFE
Yes
No
Which service are you interested in
121 parent infant therapy
Watch me play group work
Preparing for baby group work
Babys here group work
Do you have a diagnosis of neurodivergence?
Yes
No
Are you waiting for a diagnosis of neurodivergence?
Yes
No
CYPS stage of involvement?
None selected
Referred awaiting assessment
Assessment ongoing
Assessment complete
Diagnosis received
Has young person been advised they will be invited to be part of a group or take part in activities?
Yes
No
Are there any safety risks to the young person?
Yes
No
Are there any safety risks to other young people or staff?
Yes
No
Supporting documents
Maximum 3 files.
96 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.