Aid Integrated Service City Teen Advocate Services How to complete this referral: By completing this referral form, you’re helping us to make contact with the family/teenager as safely and quickly as possible. We’d appreciate it if you could include as much information as this saves the family/teenager from being asked the same questions twice and helps us to understand more about their particular needs and circumstances. If you have any questions please contact Teen Advocate Duty Desk on: 0115 8221760, Monday – Thursday 9.00am – 5.00pm How to submit this referral: To submit your referral by email please ring beforehand for the password to protect your referral documents: Email: Alternatively you can post or fax your referral to: City Teen Advocate Service Women’s Aid Integrated Services 30 Chaucer Street Nottingham NG1 5LP Fax: 0115 9472199 Eligibility Criteria: The YPVA service offers specialist support to teenagers from an accredited practitioner, focusing on those who have experienced domestic abuse in their own intimate relationship, in addition responding to other areas of violence against young women and girls both practical and emotional. The criteria’s for support into the service are below: Female Teens in intimate relationships aged 13-17years old (18 year olds with a learning disability) Female to Female violence aged 13-17 Child sexual exploitation Gang related issues Sexting, stalking and harassment Youth offending linked to Domestic Abuse Honour based violence Forced Marriage Online Grooming We provide partnership working to; Domestic Support Unit, HBV and Force Marriage unit, Equation, YOTs, Beckhampton Teenage project, The DART, Social Care, Targeted support, Teenage Midwife Team, Family Nurse Partnership alongside and schools. When we will respond: The City Team will aim to respond to your referral within 2 working days.
Does this teen have any access requirements (for example, braille documents) Yes No Don’t Know If yes, please provide details: Do they have any allergies? Yes No Don’t Know If yes, please provide details: Does this child/teen require an interpreter? Yes No Don’t Know If yes, please provide details: Teenagers equalities monitoring How would this child/teen describe their gender? Female Male Other (please specify): Don’t Know Is their current gender different to the sex they were assigned at birth? Yes No Don’t Know The 2010 Equality Act defines disability as ‘a physical or mental impairment which has a substantial and long term adverse [negative] effect on their ability to carry out normal day to day activities’ Based on the definition above, do they consider themselves to have any kind of disability? (please tick any that apply) Physical Learning Mental Health Deaf/ hearing impaired visually impaired Other (please specify): Don’t Know How would they describe their ethnicity? White British White Irish Gypsy or Irish Traveller Any other White background Asian British Asian Indian Pakistani Asian Bangladeshi Any other Asian background Chinese Arab White and Black Caribbean White and Black African White and Asian Any other mixed/ multiple background British Black African Caribbean Any other Black background Other (please specify): Don’t Know Do they have a faith/ religion?
No religion Bahai Buddhist Christian Hindu Jewish Jain Muslim Shinto Sikh Zoroastrian Other (please specify): Don’t Know What is their sexual orientation? (if age appropriate) Heterosexual/ straight Gay woman/ Lesbian Gay man Bisexual Other (please specify): Don’t Know Teenagers support vulnerabilities Please tell us more about any support needs the child/teen may have: Mental Health Physical Health Sexual Health Substance misuse Aggressive behaviour Self-harming/ suicidal feelings Issues with educational attainment/ attendance Social isolation Bullying/ bullied Experiencing abuse Other (please specify below) Additional details: 5. Services Please provide details of any services involved with the YP Agency Name Contact Details