Referral Form | Getaway Girls

Risk Factors

Given the nature of some risk factors, we have an additional form that we require for some referrals.

We advise that you complete this first (if required) and then return to the form below and attach the additional information.

Do you feel the young woman is at risk of child sexual exploitation/ criminal exploitation?

Yes

If yes to the above question, please describe and complete linked matrix:

Matrix Form

Attachment 1

One file only.
20 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

You do not need to complete an additional form.

Please complete the form below

Details of Young Woman

First Name

Last Name

Street Address

Street Address Line 2

City

Postcode

We support support girls and young women in and around Leeds

Phone Number

Ethnicity

Date of Birth

We support girls and young women age 11-25

Any additional requirements?

Details of Referrer

First Name

Last Name

Referral Organisation (if applicable):

Organisation Name

Phone Number

Referrer Address

City

Postcode

Details of the Referral

Who have you spoken at Getaway Girls about this referral (if applicable)?

The reason for the referral and the needs of the young woman?

Which other agencies are involved if any?

After reading our information, what area of work would you like to refer to?

Details of Services: https://getawaygirls.co.uk/get-involved/#groups

If you have answered 'Something Else' please provide detail