We don’t believe any child needing specialist help should have to go on a waiting list. We always carry out an initial assessment for counselling referrals and, where appropriate, will match those in need of help with specialist young people and family counsellors. To make a referral, please complete our online referral form below. Alternatively you can contact us by telephone or email. We aim to respond in most cases within 48 hours. Urgent referrals will be prioritised. MAKING A REFERRAL We need some basic information to get the ball rolling. We appreciate that some information will be sensitive so we are not asking for much detail at this stage. We can can reassure you that the details you disclose will be handled sensitively and we won’t be sharing or keeping personal information without your permission. Our systems are encrypted to the highest standards and are regularly reviewed to ensure we provide the best possible service to keep your data safe. *REQUIRED WHO IS MAKING THE REFERRAL? YOUR FULL NAME* ORGANISATION Roll/Job CONTACT DETAILS EMAIL* MOBILE/TELEPHONE* ADDRESS* ADDRESS LINE 1 TOWN CITY POSTCODE* CHILD VICTIM/WITNESS DETAILS WHO IS/ARE THE YOUNG WITNESS(ES) OR VICTIM(S) OF CRIME? NAME* ADDRESS* ADDRESS LINE 1 TOWN CITY POSTCODE* GENDER MF AGE OF CHILD ---123456789101112131415161718 ETHNIC ORIGIN CHILD’s INVOLVEMENT* Is the child a victim of, or witness (indirect victim) to the crime? VictimWitness PARENT/CARER/GUARDIAN NAME* ADDRESS* Same as aboveAdd address ADDRESS LINE 1 TOWN CITY POSTCODE ADD SECOND CHILD If this referral is for more than one child, select checkbox below (maximum 4 children/young adults per referral) Add Child NAME GENDER MF AGE OF CHILD ---123456789101112131415161718 CHILD’s INVOLVEMENT Is the child a victim of, or witness (indirect victim) to the crime VictimWitness ADD THIRD CHILD Add Child NAME GENDER MF AGE OF CHILD ---123456789101112131415161718 CHILD’s INVOLVEMENT Is the child a victim of, or witness (indirect victim) to the crime VictimWitness ADD FOURTH CHILD Add Child NAME GENDER MF AGE OF CHILD ---123456789101112131415161718 CHILD’s INVOLVEMENT Is the child a victim of, or witness (indirect victim) to the crime VictimWitness MAIN CARER’S MOBILE NUMBER MAIN CARER’S EMAIL DETAILS OF THE CRIME Please indicate the type of crime suffered by the child or young person ---Murder/ManslaughterAbuse- Sexual Abuse/Exploitation- Physical/Psychological Abuse- NeglectHate crimeBullyingOther (please specify) WHEN DID IT OCCUR WHICH POLICE FORCE IS INVESTIGATING (IF APPLICABLE)? Please summarise the circumstances of the crime and, specifically, why you are making the referral. What is/was the impact of the crime on the child or young person being referred? How has it affected their everyday life? Is the child or young person behaving differently since the crime? SUPPORT REQUIRED? What kind of help and support do you think would most help the victim/witness to recover and move on from what has happened? Please SelectEmotional support / CounsellingPractical SupportCheer up support- Theme Park Tickets- Consideration for family break funding- Other gifts Time4U - Please choose area for which you wish the referral to be made: Please SelectCambridgeshireLondon (Lamberth)HumbersideSuffolkElsewhere Please state gifts: Once we’ve received your referral, you’ll receive an acknowledgement and a unique reference number which we’ll ask you to keep safe as it will identify your application. We’ll then consider the circumstances of the case and one of our specialist team members will contact you to discuss the way forward.