42nd Street Referral Form2014

PROFESSIONAL REFERRERS:PLEASE ENSURE THIS FORM IS FULLY COMPLETED. INCOMPLETE FORMSCAN NOT BE PROCESSED AND WILL BE RETURNED TO YOU.

PLEASE CONTACT US IF YOU NEED ANY SUPPORT WITH COMPLETING THIS FORM.

Please tick to confirm that the young person consented to this referral? Yes No

Young Person contact details:

Title / First Name / Surname
Address line 1 / Date of Birth
Address line 2 / Age
Town
Post code / Ok to mail? / Yes / No
Telephone 1 / Ok to phone1? / Yes / No
Telephone 2 / Ok to phone 2? / Yes / No
Email Address / Ok to Text? / Yes / No
Preferred method
of contact (state)
Area: / Manchester / Salford / Trafford
GP Name / GP Surgery Name
Address line 1
Address line 2 / Telephone
Town
Post code / Not registered with a GP
Referrer Details:
Referral Date / Referrer Name / Role
Referrer Address
Referrer Tel No
Referrer Email
Referred by:
Family/Friend / GP / Youth Offending Team
School / IAPT Service / Probation
College / Early Intervention (psychosis) / Drugs service
Connexions / CAMHS / Hostel/Residential Unit
Youth Services / Hospital/A&E/Crisis service / Voluntary sector
Social services / Other mental health service / Other (please state below)
Gateway
If self-referral info from:
42 publicity / 42 website / Family/Friend
GP / Connexions / Mental Health Prof
Other (please state)

Identity info:

Gender: / Male / Female / Trans

Ethnicity:

White
White – English /Welsh /Scottish /Northern Irish /British / Irish
Gypsy or Irish Traveller / Any other white background, please describe
Mixed Ethnicity
Mixed White & Black Caribbean / Mixed White & Black African
Mixed White & Asian / Other Mixed Origin, Please describe
Asian
Indian / Pakistani / British Asian / Bangladeshi
Chinese / Any other Asian Background, Please describe
Black/African/Caribbean
African / Caribbean / Black British / Any other Black/ African/ Caribbean background , please describe
Other ethnic Group
Arab / Any other ethnic group, please describe

Is the young person disabled? (Please tick any that apply)

Not disabled / Physical disability / Blind/partially sighted
Deaf/hard of hearing / Learning disability/difficulty / Multiple disabilities
Unseen/invisible disability e.g. epilepsy, asthma etc / Asperger’s/Autism
Other

Is the young person a carer?

Yes / No / Unknown

Referral Details(Please provide as much information as possible):

Reason for Referral
What would you/young person like from the service?
Are there any crisis or risk issues we need to be aware of?E.g. self-harm, attempts, risk of harm to others.
Any other key services involved? (please provide details)
Has the young person got any particular access or other requirements which will need to be considered?

Appointment preferences: *Please be aware that preferences are not always available*

Appointment time: / Day / Evening[1] / Either
Preferred worker gender: / Male / Female / Either
Preferred Project Type[2]: / LGBT Project / Disabled Young People’s project / N/A

Please tick if the young person needs a community based appointment

Please tick if the young person has had a previous referral to 42nd Street

OFFICE USE ONLY:

Name of worker taking referral:

Outcome of Referral:

1.OUTCOME
(FILE MADE UP) / DATE AND TIME OF IM. / IM WORKER NAME / APPT LETTER SENT TO CONFIRM Y/N?
YP spoken to and IM appt agreed.
2.OUTCOME
(PENDING FOLDER AT FRONT OF IM W/L) / DATE LETTER SENT ASKING YP TO CONTACT US FOR AN IM. / DATE (IN LETTER) YP HAS TO MAKE CONTACT BY IF THEY WANT AN IM. Please put date on front of ref form and also in box provided.
Unable to speak to YP to offer an IM appt.
3. OUTCOME
(GO TO OUTCOME 1) / GO TO BOXES IN OUTCOME 1 AND BOOK IM APPT.
Contact from the YP (following sent letter) requesting an IM
4. OUTCOME
(CLOSE) / LETTER SENT TO REFERRER SAYING NO SERVICE REQUIRED (NSR). Y/N
No contact from YP following sent letter

Information entered onto data base by: Date:

1

[1] Last available appointment 6.00pm at our office base on Mon, Tues, Wed & Thurs.

[2] See website for details of inclusion projects.