Referral form

This form is for professional use only. If you are worried about the safety of a child, please contact First Response on 0117 903 6444.

Referrer’s Details

Young person’s details
Primary Carer’s contact details

If the young person named above is under 13 years of age, parents/carers need to be aware of the referral.

Primary Carer 1

Primary carer 2

Further details
Other agencies involved currently or in the recent past with the young person and/or family that we should know about?
Referral further details

The following boxes need to be completed in full for the referral to be assessed:

What happens next?

We will assess the information provided and will contact the person named above as the referrer within two weeks from confirmation of receipt of this form to discuss the next steps.

I understand that by completing this form, the details I have provided above will be taken, saved and stored by Creative Youth Network for data protection reasons, namely, to provide one to one support to young people. I have been advised that if I want to know more details about how Creative Youth Network deals with my information, I can ask to see the full Privacy Notice for Young People, Parents and Carers May 2018.