Making a referral

Please only complete the form if you are referring a young person (aged 10-25) who has been in custody for incidents related to Serious Youth Violence.
If you are unsure of whether a young person meets this criteria please contact us on CHRIS@talkofftherecord.org to discuss.
This form should be completed alongside the young person.
Please complete every box (where these is no information please add ‘no information’ or ‘N/A’)

Referrer details

Referrer's name *

Your organisation *

Your role *

Contact number *

Contact email address *

Young person's information

Name *

Date of birth *

Gender *

Address *

Mobile number *

Email address *

Parent/carer name *

Relationship to the young person * e.g. Mother, Uncle, Foster Parent

Parent/carer mobile number *

Parent/carer email address *

Further information:

‎1) Young person's approximate arrest date and reason for arrest. 2) Contextual issues such as home, educational, social or community issues. 3) Previous and current support in place 4) Safeguarding concerns *

‎

Young persons view:

‎ * 1

‎ * 2

‎ * 3

‎Is there anything else the young person would like to add? This could be something they would like us to know about them, thoughts or concerns, or anything else that feels important to them. *

Referrer Agreement:

‎I understand that The CHRIS Service does not share any information about our sessions without permission from the young person. In instances where there are Safeguarding concerns, The Chris Service will share information with the most appropriate person(s). This may not be myself or anyone else within my organisation. *

‎‎I understand that The CHRIS Service works transparently with young people, and therefore all information I have shared in this referral will be shared with the young person too. I can discuss this further with them at any point. *

‎I have completed this form with consent from the young person (and their parents/carer, if under 14). *

Would you like to be emailed a copy of this referral? * If yes, you'll receive an email within 48 hours.

Yes
No

‎

Making a
referral

Call us

Support Line 0800 980 7475

Croydon Service 020 8251 0251

Merton Service 020 3984 4004

Sutton Service 020 8680 8899

Email us

General enquiries info@talkofftherecord.org

Croydon Service croydon@talkofftherecord.org

Merton Service merton@talkofftherecord.org

Sutton Service sutton@talkofftherecord.org

Online Service onlinecounselling@talkofftherecord.org