Child Referrals

Whether you’re a parent, carer, or professional, please don’t hesitate to get in touch - our team is here to guide you through the process and help you find the best support possible.

Child Referral Form

About the Person Completing this Form

Referrer name
Referrer name
Relationship to child/young person
Relationship to client
Other relationship type
Other relationship type
Job title
Job title
Referrer email address
Referrer email
Referrer phone
Referrer phone

About the Child/Young Person

First name
First name
Last name
Last name
Is the child/young person aware of this referral?
Client aware?
Please explain
Reason client unaware
Date of birth
Date of birth
Child Age Group
Child's age group
Gender
Client's gender
Ethnicity
Ethnicity
Nationality
Nationality
First language
First Language

Child/Young Person Residing Address

Address type
Client's address type
Other address type
Other address type
Address line 1
Address line 1
Address line 2
Address line 2
Address line 3
Address line 3
Town or city
Town or city
County
County
Postcode
Postcode
Country
Country

Details of Person(s) with Parental Responsibility

Full name
Parent name
Relationship to child/young person
Relationship to client
Same address as client?
Same address?
Email address
Parent email
Contact number
Parent phone
Is there anyone who we should not communicate with?
Disability?
Name
Name
Relationship
Relationship
How many changes in primary caregiver(s) has the child/young person experienced?
Number of carer changes

School Details

Is the child/young person enrolled at school?
Enrolled at school?
Is the child/young person attending school?
Attending school?
Select school
Select school
School details
School details
Contact name
Contact name
Contact phone
Contact phone
Contact email
Contact email

Court Cases

Is there currently or likely to be a family court case?
Court case?
Court case notes
Court case notes

Disability or Additional Needs

Does the child/young person have a disability or additional needs?
Disability or additional needs?
Notes
Disability notes
If yes, please select the options below that most apply
Select options

Child/Young Person Medication

Is the child/young person taking medication?
Medication?
Medication details
Medication details

Child/Young Person Support

Is the child/young person currently receiving support under the following?
Select options
Social Worker Name
Social worker name
Social Worker Phone
Social worker phone
Social Worker Email
Social worker email
Team Manager Name
Team manager name
Team Manager Phone
Team manager phone
Team Manager Email
Team manager email
Other support services?
Other support?
Name of service
Name of service
Type of support
Type of support
Contact name
Contact name
Consent to contact?
Consent to contact?

Child/Young Person Trauma & Emotional Difficulties

Trauma (select as many as relevant)
Select options
Other Trauma Details
Other trauma details
Length of time since trauma
Time since trauma
Emotional difficulties (select as many as relevant)
Select options
Additional information
Trauma notes

Child/Young Person Therapeutic Support

Has the child/young person had therapy before?
Other therapeutic support?
Therapy type
Type of therapy
Therapy organisation
Location of therapy
How many therapy sessions?
Number of sessions
Therapy end date
Date therapy ended
Reason therapy ended
Reason therapy ended

Child/Young Person Risk

Is the child/young person considered to be a risk to themselves or others?
Client risk?
Risk details
Risk details

Parent/Carer Support

Do parents/carers require support?
Parent/carer support?
Support details
Support details

Additional Information

How did you hear about us?
Referral source
Referral source details
Referral source details
Is there a particular preference for therapy?
Therapy preference?
Has funding been explored?
Funding agreed?
Contribution amount
How much can be contributed?
Is there any other information you wish to provide?
Additional information