Referral Form | Geeza Break

Referrer Details

Referrer agency

Referrer name*

Referrer email*

Referrer phone

Preferred contact times e.g., Weekdays 10–2

Family / Carer

Parent/Carer name*

Contact number* Mandatory contact number for the family

Date of birth (Parent/Carer) Date of birth of the parent/carer

Ethnicity Please select your ethnicity (optional)

Reason for referral Primary reason for this referral

Street address*

Street address line 2

City

Postcode* e.g. G31 4ST

Interpreter required? Where possible, Geeza Break will ask the referring agency to provide the interpreter so support can take place.

Joint visit required? Select if another professional needs to attend the first visit with Geeza Break.

Re-referral

Is this a re-referral?

If yes, approximate time of last support received Month/Year is fine (e.g. 05/2024)

Important: Due to high demand for our services, please note that we are currently prioritising first-time referrals.
If you feel your situation is urgent or involves a safeguarding concern, please contact the office on 0141 573 2900.

Services Requested

Family SupportWorking 1:1 with parents to focus on the needs of the family unit. This can include parenting support, help with poor mental health, and supporting children with additional support needs (ASN). Respite SittingSupport for children within the family home and in the community, for 4 hours once a week, for up to 8 weeks. Respite CareOvernight respite in an approved carer's home, once a week for a period of 8 weeks. Geeza ChanceA 10-week programme for children aged 8–16 in kinship care. It offers group activities and workshops designed to build confidence, social skills, and life skills. Kinship Care1:1 support for carers, focusing on the needs of the family unit. This can include parenting support, advocacy, emotional support, and help with children who have additional support needs (ASN).

Brief reason for referral / goals

Additional Information

Details of children in the household 1 form(s)

Child name*

Date of birth*

Relationship*

Additional support needs / disability

School/Nursery (optional)

Remove this child

Referral criteria Select all that apply

Child/young person mental health

Safeguarding / child protection

Addiction / substance misuse

Experience of the criminal justice system

Kinship care

Other (optional)

Geography

HSCP locality* North East, North West or South

Ward* Not sure? Find my ward

Neighbourhood (optional)

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