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
Which educational establishment studying at
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Newcastle University
Northumbria University
Newcastle College
Sunderland University
Other (please state below)
Prefer not to say
Other establishment
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Contact options - validation
Street
City
Postcode
Can we write to this address
Mobile Phone
Can call mobile
Can leave message on mobile
Can text to mobile
Email
Can email
Preferred method of communication
Other information about making contact
Support / communication needs for accessing the services
Date of birth (dd/mm/yyyy)
Sexual orientation
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Bisexual
Gay / lesbian
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
Prefer not to say
Additional mental health needs
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Yes
No
Prefer not to say
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)
Prefer not to say
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