Who is this referral for?
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Me
Someone else
What is your relationship with the client?
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Professional
Friend / family / third party
Source of referral
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CJS: court-based witness service
CJS: courts
CJS: other
CJS: police
CJS: probation
Health: GP
Health: IAPT
Health: mental health services
Health: other
Housing
Local authority: adult services
Local authority: children's services
Local authority: other
SARC services
VFN
Voluntary sector
Women's sector: DV
Women's sector: other RC
Women's sector: other
Other
Health, state which:
Housing, state which:
CJS, state which:
Local authority, state which department:
Women's sector, state which:
Other, state which:
State which (e.g. Youth services):
Continuing to work with client
Referrer's name
Referrer's phone
Referrer's email
Referrer's address
Referrer's relationship with client
Permission to make referral
First name
Last name
Service(s) you / they would like:
Counselling
Group Work
Practical and Emotional Support
Information and Advice
Not sure
Living in area
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Gateshead
Newcastle
North Tyneside
Northumberland
South Tyneside
Sunderland
Out of area
Working in area
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Gateshead
Newcastle
North Tyneside
Northumberland
South Tyneside
Sunderland
Out of area
Not known
Studying in area
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Gateshead
Newcastle
North Tyneside
Northumberland
South Tyneside
Sunderland
Out of area
Not known
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Street
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Email
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Date of birth (dd/mm/yyyy)
Sexual orientation
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Bisexual
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Heterosexual / straight
Other
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Gender
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Woman
Non-binary
Transwoman
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Disability
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Yes
No
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Additional learning needs
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Yes
No
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Additional mental health needs
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Yes
No
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Ethnic origin
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Asian / British Asian (including Chinese, Indian, Pakistani, Bangladeshi and any other Asian background)
Black / African / Caribbean / Black British
Mixed / Multiple Ethnic Groups (White and Black Caribbean, White and Black African, White and Asian, Any other mixed / multiple ethnic background)
White (English, Welsh, Scottish, Northern Irish, Irish, Gypsy, Irish Traveller, Any other White background)
Other ethnic group (including Arab and any other ethnic group)
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Reported to police
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Yes - the only incident / all the incidents
Yes - some, but not all of the incidents
No
Recent child rape / sexual assault
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Yes
No
Recent rape / sexual assault
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Yes
No
Historic rape / sexual assault
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Yes
No
Historic child sexual assault
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Yes
No
Other form of sexual violence
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Yes
No
Notes about abuse
Preferred counselling base
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Gateshead
Newcastle Central
Newcastle West End
North Tyneside
Northumberland
South Tyneside
Contact Information