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CRUSH referral form

Please note that all referrals will be reviewed individually to ensure that the attendees get the most out of the group. Not all applicants will be chosen to attend due to group dynamics, age groups, etc.
If you are not successful you will be informed and added to a list for the next group.

Referrer Contact Information

Young Person

Is school/college aware of CRUSH referral?
Is the young person's parent/guardian aware of CRUSH referral (if the young person is under 16)?
What type of abuse is the young person experiencing? Please tick all that apply
Is the young person being supported by another agency, such as social care, probation, mental health, substance worker, YOS?
Is or has the young person been exposed to domestic abuse at home?
Is the young person at risk of domestic abuse in their current relationship?
Has the young person experienced domestic abuse in a past relationship?
Is the young person known to be violent or aggressive?
Is the young people dependant on anything, such as drugs, alcohol, or solvents?
Does the young person have a child protection plan in place or involvement with Social Services?
Is the family involved in a CAF (Common Assessment Framework)?
Is the family involved or been involved with MARAC (Multi Agency Risk Assessment Conference)?
Can the young person safely attend a session and keep the service and venue confidential from any abusive party?
Does the young person have any medical conditions, disability or mobility problems, or problems using stairs, or visual/hearing impairment?
Is the young person from a BMER (black, minority, ethnicity, refugee) or cultural group?

Person Causing Harm

Are there any orders in place which prevent contact with the young person?

Parent/Guardian Details

We cannot provide transportation for any young person attending this group. The referring agency will be expected to arrange provisions for them to attend.




Contact us

Phone: 01452 726570 or Email:

Online referral form | Feedback form