RISE referral form

  1. RISE referral form

If you think RISE could help you or a young person you know or work with, please complete the onlin referral form below, or contact Wasu, our Youth Empowerment Manager, to find out more call/text/WhatsApp on 07485 931 201, or email RISE@ch1889.org

RISE Referral
Is this a self-referral?

Details of the worker making the referral (if applicable)

Details of the young person being referred

Young person's support requirements

Please check each area of support that applies to the young person. And provide details against each area ticked.

'Soft' skills and social skills (confidence, teamwork, motivation, communication skills, resilience)
Behaviour management (conflict resolution, anger control, emotions regulation)
Mental health concerns
Physical health concerns
Learning disabilities/difficulties
Not in employment, education or training (at risk or exclusion)
Substance misuse
Victim of abuse/bullying
Criminal/anti-social activity/gang-affiliation
LGBTQI support needs
Destructive relationships (fractured family life, abusive partners, lack of positive peer support)
Other support needs

Safeguarding concerns

To ensure the safety of all staff and participants of the RISE programme, please provide details of any significant risk posed by/to the Young Person.

(Please provide detailed comments to support our priority of keeping all members of the programme as safe as possible)

Please check each Safeguarding Concern that applies to the Young Person and provide details against each area that you have checked.

Regular Substance Misuse
Acts of violence
Gang participation
Areas of London in which the young person feels unsafe
Other safeguarding concerns

Any additional information that may affect the young person's experience of the RISE youth programme should be noted below.

Young Person's Permission to Disclose Information to a Third Party

Have you obtained the young person's permission for us to contact them by phone?

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