YWP Service

Young Women’s Project Referral Form

Please complete this form as fully as you are able. If any fields on this form are not completed we may need to contact you to request more information; this may delay the progress of your referral.

Which service(s) does the young woman require?

☐ Young Women’s Advocate (one to one support)

☐ Group Work (workshop programme)

☐ Counselling

Referrer Details
Name of referrer / Click here to enter text. / Contact number(s) / Click here to enter text.
Role/position / Click here to enter text. / Email address / Click here to enter text.
Agency / Click here to enter text. / Postal address including borough / Click here to enter text.
Referral date / Click here to enter text.
Has the young woman consented to this referral? / ☐ Yes ☐ No
Has the parent(s)/guardian(s) of this young woman consented to this referral? / ☐ Yes ☐ No
Is the young woman happy to give emergency contact details for her parent(s)/guardian(s)? / ☐ Yes ☐ No
If so, please provide emergency contact details for parent(s)/guardian(s). / Click here to enter text.
Young Woman’s Details
Name / Click here to enter text. / Known as/preferred name / Click here to enter text.
Age / Click here to enter text. / Date of birth / Click here to enter text.
Contact number(s) / Click here to enter text.
Safe method of contact? ☐ Yes ☐ No
Email address(es) / Click here to enter text.
Safe method of contact? ☐ Yes ☐ No
Address including borough / Click here to enter text.
Safe method of contact? ☐ Yes ☐ No
Preferred method(s) of contact / ☐ Call ☐ Text ☐ Email ☐ Letter
Are there any language or literacy issues? If so, provide details. / Click here to enter text.
Is the young woman in education? / ☐ No ☐ Yes, full-time ☐ Yes, part-time
If yes, please provide contact details for the institution and a named contact. / Click here to enter text.
Is the young woman employed? / ☐ No ☐ Yes, full-time ☐ Yes, part-time
Is the young woman pregnant?
If yes, provide details. / Click here to enter text.
Does the young woman have any children or childcare/caring responsibilities?
If yes, provide details. / Click here to enter text.
Presenting Issues and Concerns
Please tick all that apply to the young woman that you are referring, and provide further details in the Reasons for Referral section below.
☐ Rape / ☐ Sexual assault / ☐ Sexual harassment/bullying (including online)
☐ Sexual exploitation / ☐ Trafficking / ☐ Serious youth violence/gang related violence
Other Experiences of Violence and Concerns
Please tick all that apply to the young woman that you are referring, and provide further details in the Reasons for Referral section below.
☐ Domestic violence / ☐ Stalking
☐ Forced marriage / ☐ FGM / ☐ ‘Honour’-based violence
☐ Self-harming behaviour / ☐ Low self-esteem/confidence / ☐ Suicidal ideation
☐ Suicide attempt(s) / ☐ Mental health issues/concerns / ☐ Recent bereavement/loss
☐ Homeless / ☐ In hostel/temporary accommodation / ☐ Estranged from family
☐ LAC / ☐ Care leaver / ☐ Young carer
☐ Historic/current social care involvement / ☐ Repeated STIs/pregnancies/terminations
☐ Criminality / ☐ Concerns of substance (mis)use
☐ Involved with gang/serious youth violence / ☐ Associated with gang/serious youth violence
☐ Experienced/concerns of emotional abuse / ☐ Experienced/concerns of physical abuse
☐ Experienced/concerns of neglect / ☐ Witnessed domestic violence
☐ Witnessed other forms of violence / ☐ Parent/family member experienced sexual violence
☐ Parent substance use issues / ☐ Parent mental health issues / ☐ Parent criminality issues
☐ Concerns/issues with online safety / ☐ Periods of being missing from home/care/school
☐ Experiences/concerns of grooming / ☐ Associated with others who are sexually exploited
☐ Other violence experienced (please outline in Reasons for Referral section).
If There Are Experiences of Violence
When did the violence occur? / ☐ Recent (within the last year) ☐ Historic (over a year ago)
How old was the young woman when the violence happened? / Click here to enter text.
Is there repeat victimisation/violence occurred multiple times? / ☐ Yes ☐ No
Group/multiple perpetrators? / ☐ Yes ☐ No
Is/are the perpetrator(s) known to the young woman? / ☐ Yes ☐ No
Who were/are the perpetrators? Tick all that apply.
☐ Partner/boyfriend / ☐ Ex-partner/boyfriend / ☐ Relative/family member
☐ Peer/school colleague / ☐ Gang-member / ☐ Acquaintance
☐ Stranger / ☐ Other, provide details:
Reporting to Police
Have any incidents of violence (perpetrated against the young woman) been reported to the police?
☐ Yes / ☐ No / ☐ Unknown
Crime Reference No. / Click here to enter text.
OIC/SOIT name and contact details / Click here to enter text.
Statements/ABE completed?
☐ Yes / ☐ No / ☐ Unknown
Criminal court process ongoing?
☐ Yes / ☐ No / ☐ Unknown
If court process ongoing, provide court date if known. / Click here to enter text.
Reasons for Referral
Please outline the reasons for your referral and provide any further details around the above presenting issues and concerns, particularly in relation to safeguarding issues and risks/vulnerabilities/indicators identified.
Click here to enter text.
Involvement with Other Agencies
Please indicate the young woman’s involvement with the following services.
Agency / Past Involvement / Present Involvement
If yes, provide contact details for named worker.
GP/health services / ☐ Yes / ☐ Yes Click here to enter text.
Social care / ☐ Yes / ☐ Yes Click here to enter text.
Police (CAIT/SAPPHIRE/local) / ☐ Yes / ☐ Yes Click here to enter text.
CAMHS/mental health/counselling services / ☐ Yes / ☐ Yes Click here to enter text.
Substance use/drug & alcohol services / ☐ Yes / ☐ Yes Click here to enter text.
Connexions/youth agencies / ☐ Yes / ☐ Yes Click here to enter text.
YOT/probation/diversion schemes / ☐ Yes / ☐ Yes Click here to enter text.
Haven/SARC / ☐ Yes / ☐ Yes Click here to enter text.
GUM/sexual health services / ☐ Yes / ☐ Yes Click here to enter text.
Refuge/housing/homelessness services / ☐ Yes / ☐ Yes Click here to enter text.
Other voluntary organisation / ☐ Yes / ☐ Yes Click here to enter text.
Learning disability services / ☐ Yes / ☐ Yes Click here to enter text.
Other / ☐ Yes / ☐ Yes Click here to enter text.
Does this referral form part of a care/support plan or order?
☐ Yes / ☐ No
If yes, please specify and provide name/contact details of lead worker.
Click here to enter text.
Please note that if the young woman is accepted for one-to-one support with the YWP service, details of this plan and the most recent assessment should be provided when requested.
Additional Information
Please provide any additional information that we should be aware of e.g. additional needs/learning disabilities, substance use issues, NRPF, immigration status etc.
Click here to enter text.
Monitoring Information
If this section is not completed then referrals will be returned.
How did you (referrer) find out about our service? / Click here to enter text.
Does the young woman identify as transgender?
☐ Yes / ☐ No / ☐ Prefer not to say
Sexual orientation (if client is over 16 years old)
☐ Bisexual / ☐ Heterosexual / ☐ Lesbian
☐ Unsure / ☐ Other / ☐ Prefer not to say
Ethnic background
☐ Asian British / ☐ Black British / ☐ Chinese / ☐ White British
☐ Asian Bangla / ☐ Black African / ☐ Latin American / ☐ White Irish
☐ Asian Indian / ☐ Black Caribbean / ☐ Middle Eastern / ☐ White European
☐ Asian Other / ☐ Black Other / ☐ Mixed Ethnicity / ☐ White Other
☐ Roma/Traveller / ☐ Prefer not to say / ☐ Other (specify): Click here to enter text.
Does the client have any disabilities? Please tick all that apply.
☐ Yes (please specify below) / ☐ No / ☐ Registered disabled
☐ Blindness/visual impairment / ☐ Deaf/hearing impairment / ☐ Learning/cognitive difficulty
☐ Mental health / ☐ Mobility difficulty / ☐ Prefer not to say
☐ Other (specify): Click here to enter text.
Religion
☐ Agnostic / ☐ Atheist / ☐ Baha’i / ☐ Buddhist
☐ Christian / ☐ Hindu / ☐ Humanist / ☐ Jain
☐ Jewish / ☐ Muslim / ☐ Rastafarian / ☐ Sikh
☐ None / ☐ Prefer not to say / ☐ Other (specify): Click here to enter text.

Once you have completed the form, please email to either (including by Egress Switch) or .

You may also fax to 020 8840 2958, however if faxing your referral please call the YWP team on 020 3441 0179 to confirm that this has been received.

For WGN Office Use Only
Date referral received:
Click here to enter text. / Date referrer contacted:
Click here to enter text. / Date client/parent/carer contacted:
Click here to enter text.
Referral outcome: / ☐ 121 / ☐ Group / ☐ Advice / ☐ Counselling
☐ WGN other / ☐ DNMC / ☐ At capacity / ☐ YW refused
☐ Other (please specify): Click here to enter text.
Allocated YWA: / ☐ Ealing / ☐ Home Office / ☐ H&F

WGN YWP Referral Form Page 2 of 6

Updated August 2015

PRIVATE AND CONFIDENTIAL ONCE COMPLETE