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Referral form

Before making a referral, please take our eligibility questionnaire to ensure your patient or service user is eligible for Safety Net. We also ask that you read the information on this website page to help you assess whether your service user is ready for our service right now.

To ensure we can process your referral efficiently, please complete all sections of this form. If you have any questions or would like to speak to someone before making a referral, please call our office on 01228 515859, and we can arrange for you to speak to a member of our duty team.

Please ensure the ‘General Data Protection Regulations UK GDPR’ section is completed. This section is crucial as it gives us your client’s consent to collect and use their data to provide support.

Important Information

Incomplete or unsigned referral forms will be returned or securely disposed of. Please ensure all required sections are completed and signed. You will be notified by email within 2 business days if the referral form is incomplete.

  • We are not able to provide immediate support due to waiting lists.
  • We consider a client to be “held” by us only when they begin attending sessions.
  • We will keep you informed about the client’s suitability for our services and their progress through the process.
  • All client information is treated with strict confidentiality.
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Before you begin your referral

To support a smooth and timely process, please be aware of the following steps once a referral is submitted:

1. Referral screening
All referrals are reviewed by our team to assess suitability for the service. We may contact you for further information if needed.

2. Consent and booking
If appropriate, the individual/ parent or carer will be sent a link (via text or email) to complete our consent form. Once completed, they will be able to book an initial call at a time that works for them.

If this process is not appropriate for your client (for example, due to access/ disability needs), please let us know at the point of referral.

3. Booking expectations
Clients are not required to have their initial call within a set timeframe, but they do need to book their initial call. Appointment slots are available across a 30-day period to offer flexibility.

If a call has not been booked within one week, we will send a reminder. If no booking is made after a further week, the referral will be closed and you will be informed.

Waiting times and pathway
We currently operate a waiting list for our trauma-informed support and therapy services, so support is not available immediately following referral.

Once a referral is accepted and the initial call has taken place, the individual will be placed on a waiting list for an assessment. Assessments are completed when they reach the top of the list to ensure information remains current and relevant.

Following the assessment, if the service remains appropriate, we will look to allocate the individual to the next available suitable support.

Please note: the waiting time between the initial call and assessment may currently be up to 12 months.

While individuals are waiting, we can offer signposting, information, and advice where needed.

Contact information and referral context

Please consider if you are the best agency to make this referral. Another agency with more involvement or knowledge of the client’s situation may be more appropriate.

Please note that if we are unable to do so, we will return your referral.

Need and risk assessment

Include information about; diagnosis, presentation, symptoms, medication.

Include information about; nature of concerns, professionals involved, current level of risk.

Include information about; what substances are being used, frequency and amount whether they are receiving any support for this and if yes, what and who from.

Include information about; physical (e.g. mobility, stairs), sensory (e.g. hearing, vision), communication (e.g. language, learning) and if a translator is required, please specify the language.

Client information

This information helps us understand the diversity of the people we support and ensure we are meeting their cultural needs and used in line with our GDPR.

Address

E.g. If client is a young person living with a parent/carer but has their own mobile/email address and it is ok to contact them on it.

Referral information

Please provide details about the reason for referral, including: what the client hopes to achieve through support, specific challenges or issues the client is facing and any relevant background information or contributing factors.

Include; name, contact number, email address and police force.

i.e. social workers, school, police, SARC, Bridgeway, ISVA or IDVA.

i.e. social workers, school, police, SARC, Bridgeway, ISVA or IDVA.

i.e. social workers, school, police, SARC, Bridgeway, ISVA or IDVA.

General Data Protection Regulations UK GDPR

If the referral is made by a third party, the worker must ensure the client understands the information above and has given their consent.

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