EmpowerHER Young Mums Safe Space/Service Referral Form

EmpowerHER Safe Space Referral Form

This form is designed to refer young and teen mums aged 16-23 who are vulnerable or at risk of violence, exploitation, and abuse. By providing detailed information, you help us understand the unique needs and circumstances of each young mum, allowing us to offer tailored support and services.

Please fill out the form with as much detail as possible. All information provided will be kept confidential and used solely for the purpose of providing the best support to the referred individual. If you have any questions while completing the form, please contact us at info@animayouth.co.uk.

Thank you for your referral and your commitment to supporting young mums in our community.



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Agency/Organisation Name referring (If Applicable)
Position (if referring):
Referrer's Relationship to Client (if referring)
Contact Person (Whom is completing the form):
 *
Phone Number:
 *
Email Address:
 *
Client Information
Full Name:
 *
Date of Birth:
 *
MM
/
DD
/
YYYY
Address:
 *
Phone Number
 *
Email Address (if any)
 *
Preferred Method of Contact:
 *
Required
Parent/Carer Information (if applicable for teen mums):
Name, Relationship to Client, 
Phone Number:
Email Address:
 *
Current Living Situation:
 *
If answered 'Other' above please give details *

Reason for Referral:

Please provide a brief description of why the young mum is being referred or if self referring, why you would like to access the EmpowerHER Safe Space & Support Services
*
Safe Space Services Required (check all that apply):
 *
Required

Needs Assessment:

Key areas of concern (check all that apply):
 *
Required
If answered 'Other' above, please specify *

Risk Assessment:

Is the client/ or you are currently experiencing or at risk of any of the following (check all that apply):
 *
Required
If answered 'Other' above, please specify *
Please provide any details about the client's risk factors, including any known safety concerns or previous incidents (if referring)
*

Consent to Share Information:

 *
Required
Signature of Referrer (Please Name & Date)

 *

Additional Notes:

Please add any other relevant information or specific needs the client has mentioned that would assist in providing targeted support:
 *
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