Self Referral Form

Our Victims of Crime counselling/SAFE Project are temporarily closed due to reaching maximum number of referrals for the year so far. Please contact katie.graham@children-ne.org.uk for details on when the contract will be reopening and for any other information. Thanks

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.
Your details
Who is your primary Parent/Carer?
What is their relationship to you?
Do you have any disabilities?
Do you need the help of an interpreter?
Preferred Communication Method(s)
Privacy Preferences
Your Emergency Contact
Referral details
Reasons for referral
If you are referring on behalf of someone please confirm the person/family are aware the referral is being made.
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?
School
Is the School/ College/ University aware that this Referral has been made?
GP
Is the GP aware that this referral has been made?
Are you / is the person/family currently subject to a child protection plan/child in need plan/early help plan?/LAC
Are you a carer?
Are you currently on a waiting list for an assessment with any other organisation please state which waiting list and what for?
Additional service questions and supporting documents
Self Harm
Suicidal Ideation
Offending
Addictions
Has there been a suicide attempt in the last 12 weeks?
This is not a diagnostic service. Please tick to confirm this is understood at referral
NEET
Confidence building
Support to attend appointments
Support to access activities
Support with CVs , job applications etc
Children removed from parents care
Children at risk of being removed
Rehabiltiation support package
Current court proceedings
substance misuse
Parenting concerns
Child protection concerns
SGO support package
Struggling to meet child/rens needs
Neglect
Physical abuse
Sexual abuse
Emotional abuse
Are you engaged with the criminal justice system?
Are you engaged with the criminal justice system?
Would you require the family support element of SAFE
Do you have a diagnosis of neurodivergence?
Are you waiting for a diagnosis of neurodivergence?
Has young person been advised they will be invited to be part of a group or take part in activities?
Are there any safety risks to the young person?
Are there any safety risks to other young people or staff?
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