REFERRAL FORM

GENERATION:HER

Thank you for referring a young person to the GENERATION:HER programme delivered by Liberty Una CIC.

This programme supports girls and young women aged 16–25 who may be affected by domestic abuse, harmful relationship dynamics, or experiences of other forms of gendered based violence and abuse.

Please complete this form with as much information as possible. The information provided will help us assess suitability for the programme and ensure appropriate safeguarding and support measures are in place.

SECTION 1 - REFERRER DETAILS

Referrer name: *

Job Title/Role: *

Organisation/Service: *

Email address: *

Phone number: *

Relationship to Young Person: *

How long have you know the young person? *

Has the young person consented to this referral? *

Yes

No

If no, please explain:

SECTION 2 - YOUNG PERSON DETAILS

Young Person's Name: *

Preferred Name: *

Date Of Birth *

Age: *

Ethnicity: *

Pronouns (if applicable):

Address

Street Address

City

County

Country

Postal Code

Young Person Phone number: *

Young Person Email Address *

Emergency Contact Name and Relationship: *

Emergency Contact Number: *

Parent/Carer Details (if applicable):

SECTION 3 - CURRENT CIRCUMSTANCES

Please provide any relevant details:

SECTION 4 - REASON FOR REFERRAL

Please explain the concerns, experiences or behaviours that have led to this referral.

This may include:

· Peer conflict

· Aggression or harmful behaviour

· Relationship violence

· Emotional dysregulation

· Trauma responses

· Exploitation

· Criminalisation concerns

· Family conflict

· School or community concerns

· Harmful relationship dynamics

Please Provide as much context as possible: *

SECTION 5 - STRENGTHS & PROTECTIVE FACTORS

Please tell us about the young person’s strengths, interests and positive support networks. *

What helps them feel safe, calm or regulated? *

What positive relationships or support systems do they currently have? *

SECTION 6 - RISK & SAFEGUARDING INFORMATION

Please provide details: *

Are there any known triggers, risks or concerns we should be aware of in relation to group participation? *

SECTION 7 - GROUP READINESS

In your opinion, is the young person currently able to:

Engage safely within group discussions? *

Yes

No

Unsure

Manage any conflict with support? *

Yes

No

Unsure

Respect confidentiality within a group setting/environment? *

Yes

No

Unsure

Participate without posing significant risk to other people? *

Yes

No

Unsure

What support may help them engage successfully? *

SECTION 8 - ACCESSIBILITY & SUPPORT NEEDS

Please outline any additional support needs or adjustments required.

This may include:

· Neurodivergence

· Learning difficulties

· Mobility/accessibility needs

· Sensory needs

· Language/interpreter needs

· Anxiety support

· Dietary requirements

· Cultural or religious considerations

Details: *

SECTION 9 - PROFESSIONAL INVOLVEMENT

Please list any professionals/services currently involved with the young person.

Service/Professional
Contact Name
Contact details

If more than one professional, add details below:

SECTION 10 - CONSENT & INFORMATION SHARING

I confirm that: *

The information provided in this referral is accurate to the best of my knowledge.

The young person has been informed about this referral.

Appropriate consent has been obtained for information sharing.

I understand that confidentiality may be broken where there are safeguarding concerns or risks of harm.

Referrers Name: *

Signature: *

Clear

Date: *

Email: [email protected]

REFERRAL FORM

GENERATION:HER

SECTION 1 - REFERRER DETAILS

SECTION 2 - YOUNG PERSON DETAILS

SECTION 3 - CURRENT CIRCUMSTANCES

SECTION 4 - REASON FOR REFERRAL

SECTION 5 - STRENGTHS & PROTECTIVE FACTORS

SECTION 6 - RISK & SAFEGUARDING INFORMATION

SECTION 7 - GROUP READINESS

SECTION 8 - ACCESSIBILITY & SUPPORT NEEDS

SECTION 9 - PROFESSIONAL INVOLVEMENT

SECTION 10 - CONSENT & INFORMATION SHARING

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