PDAP Young Person Referral Form

Please Fill in the form Below

How to complete this referral:

By completing this referral form, you’re helping us to contact the client as safely and quickly as possible. We’d appreciate it if you could include as much information as possible – this saves the client from being asked the same questions twice and helps us to understand more about their needs and circumstances.

Eligibility criteria for this service:
Please be sure to check that the client meets the following criteria before making the referral:

Alternative Form Download

If you do not wish to fill in the form below you can download the form and print it off and send it back to us by post.

Simply hit the button below to download the paper version of our form and fill in as much information as possible and send it back to us.

Download YP Form

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Referral Details

Child Information

(please specify in what capacity the contact occurs i.e. living in the same home, supervised contact, no contact, in a relationship with)

Support Needs

Involved Professionals, current or previous

Please give details of all other professionals, agencies and carers who are involved in supporting the applicant (use separate sheet if needed). This may include, for example, Welfare Rights Services, Drug Workers, CPNs, Doctors, Psychiatrists, Social Workers.

Reasons for referral:

(please provide as much information about the child’s experience of domestic abuse as possible: Stalking and harassment, severity of domestic abuse incidents, recent incidents, child’s exposure to DA)

(please detail any substance misuse, mental health or self-harm)

Please Print full name for signature

Our Young Peoples Service provides support for young people aged 14 – 18 in schools/ colleges and other community settings.

We work to improve young people’s confidence , self-esteem and coping strategies allowing for them to explore their feelings, thoughts and hopes for the future.

This can be facilitated in one to one or groups sessions covering a range of activities focussing on:

  • What is domestic abuse
  • Abuse within intimate / family relationships
  • Healthy relationships
  • Early intervention
  • Age-appropriate safety planning
  • Revenge Porn / Sexting and Online Safety
  • Grooming and Child Sexual Exploitation
  • Honour Based Violence
  • Consent and Sexual Health
  • Coercive and Control