Referral Form – Children & Young People Service
About the Child/Young Person
| Childs Name | |||
| Date of Birth | |||
| Age | |||
| Address | |||
| School Attended | |||
| Does the child have any additional requirements? | |||
| Is the child/young person on the child protection register? | |||
| Does the Child/Young Person have a social worker (if yes please provide details) | |||
| Other agencies involved with child | Yes | No | Unaware |
| If Yes, please tell us about these services | |||
| Reason for Referral – Please tell us why you want to refer the child/young person. Please include: Details of domestic abuse Behaviour issues e.g. withdrawal, anger, sadness etc relationships with families/friends | |||
| What relationship is the perpetrator to the child? | |||
About the Parent/Carer
| Does the child/young person live with both parents | Yes | No |
| Name of Parent/Carer who has consented to referral | ||
| Telephone Number of Parent/Carer consented to referral | ||
| Email Address of Parent/Carer consented to referral | ||
| Young person’s contact details (if appropriate) | ||
| Are both parents aware of the referral? | Yes | No |
| If not, please give reason | ||
| Name and role of referrer | ||
| Address of referrer | ||
| Telephone number of referrer | ||
| Email address of referrer |
Please tick which you think is the lead need for child you are referring:
DASH STAR 4-6/ 7-11
STAR prevention Drawing and Talking
RYPP/ Break4change
CarmDAS supported a total of 783 individuals, 453 Adults and 330 Children supported in 2023-24 who experienced domestic abuse
www.carmdas.org – Click on hyper link to view CarmDAS impact report 22/23
Please note , My working hours are :
09.00am – 16.00pm Monday to Friday
I will not have access to my emails outside of these hours. If there are any urgent queries outside of my working hours, please contact CARMDAS on 01267 238410
Tel/Ffon: 01267 238410
Tel/Ffon : 07779889729
AnneMarie.Maslin@carmdas.org
Ty Myrddin, Cambrian Place
Carmarthen SA31 1QG.
Llandeilo Community Hub 