Referrer Information

Please tell us who you are *

A young person wanting help (aged 5-19 or up to 25 years for those with additional needs) A professional involved in a child, young person or family’s care

A parent/family member/carer requesting support

Form for a parent/family member/carer requesting help

The information you provide is confidential. If any of the information you have given us suggests that you or someone else is at risk we may need to share this with other organisations.

Please check the box to confirm you are happy for your information to be shared in this way and for us to contact you on the number you give us *

I confirm

If you are unable to complete this form or you do not wish to check the box above please ring us instead on 0300 304 5555.

Please tell us your relationship to the child/young person *

Relative Other

Carer

Please tell us how you are related e.g. Mother, Father, Aunt, Uncle, Grandparent etc. *

Please tell us what kind of care you provide e.g. foster care, homecare etc. *

Please tell us your relationship to the child/young person *

Details about child/young person

First name *

Last name *

Date of birth *

Address *

Form for Professional involved in the child/young person’s care

The information you provide is confidential. If there is a risk to the safety of the child, young person or others, the information may be shared with relevant authorities outside of the partnership.

Please check the box to confirm you are happy for your information to be shared in this way and for us to contact you on the number you give us *

I confirm

Has parent/carer(s) consent been gained? *

Yes

Is the child deemed Gillick competent and has consent to this referral? *

Yes

This referral will be declined as consent must be gained. Please gain consent and then return here to make the referral.

Safeguarding issues should be referred to social care via 01484 414960

What is the child/young person's main spoken language? *

What is the child/young person's religion? *

Is an interpreter needed? *

Yes

Are there any communication needs for this child/young person or their parent/carer? *

Yes

For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s.

What might be helpful when communicating with this child/young person their parent/carer?

Details about you, the person requesting the support on behalf of the family/child/young person

First name *

Last name *

Address *

Role/Job Title *

Organisation Name *

Email Address *

Phone Number *

What support is being requested?

Details of Lead professional or health visitor (if applicable)

Teacher details

Are you aware of any other professionals involved in their care? Please provide details. *

Young Person options for form

The information you provide is confidential. If any of the information you have given us suggests that you or someone else is at risk we may need to share this with other organisations.

Please check the box to confirm you are happy for your information to be shared in this way and for us to contact you on the number you give us *

I confirm

Your GP may also be able to see that you have asked us for help, your GP is a health professional who also must keep information confidential. Please tick below to say that you are ok with this. *

I confirm

If you are unable to submit this form for any reason please ring us instead on 0300 304 5555.

First name *

Last name *

Date of Birth *

Phone Number *

Email Address

Address *

Please tell us more about how we can help you *

What is your main spoken language? *

What is your religion? *

Do you need an interpreter? *

Yes

Are there any communication needs for you or your parent/carer? *

Yes

For example, related to learning disabilities or autism or due to impaired sight/hearing or any other reason/s.

What might be helpful when communicating with you or your parent/carer?

Support for 5-19 age group