Bridging the Gap

Bridging the Gap

REFERRAL FORM

Please download and save a copy of this form to your computer. Once you have completed this please re-save and e-mail to along with any supporting document.

Name / DOB
Current Address
Next of Kin
National Insurance Number
National Health Service Number
Social Worker / Date Completed
Contact telephone No
Pen Picture

Please attach a copy of current pathway plan and any relevant assessment reports or risk assessments.

It is extremely important that this form is completed with as much detail as possible. Our decision to accept the Service User into Bridging the Gap is based on this information. It is also in the Service Users best interest that Bridging the Gap has detailed information, so we may provide the best service possible.

Level of support required

24 hours staffing / Daily visiting staff
7 day daytime staff on site / Outreach Support
Yes / No
Is the Service User registered disabled
Can the Service User speak English
Is the Service User literate in English
Does the Service User have sensory disabilities
Please specify

Service Users ethnic origin

Please tick the box next to the category which you think best represents Service Users ethnic origin (if they do not wish to give this information please tick the box marked question refused).

White
British / Irish
Any other white background:
Mixed
White and Black Caribbean / White and Black African
White and Asian
Any other Mixed background:
Asian or Asian British
Indian / Pakistani
Bangladeshi
Any other Asian background:
Black or Black British
African / Caribbean
Any other Black background:
Chinese or other ethnic group
Chinese
Any other ethnic background:
Question refused

PERSONAL INFORMATION

Please give us enough information to safeguard this young person in line with your safeguarding policy, and to allow us to match this person to our provision.

What is the young person’s legal status?
Is the young person currently undergoing therapy? (If so what day of the week does this take place and at what venue?) If therapy is not being taken is this being considered.
When was young person’s LAC Medical undertaken? (if applicable)
When was the young person’s last Opticians Appointment, and what was the outcome of this?
When was the last GP appointment
When was the young person’s last Dental Appointment, and what was the outcome of this?
Are there any medical needs that we need to be made aware of?
Is the young person on any medication?
Is the young person allergic to anything (i.e. Medication, Foods, Materials etc)
Does the young person have a partner and is this relationship positive, if not why
Is the young person pregnant or expecting a child with their partner?
Is the young person taking any contraceptive?
If the young person is under LAC, when was their last review, and what were the previous decisions?
Does the young person smoke, drink alcohol, take drugs, if yes please explain how much per week and what is taken?
What is young person’s cooking abilities?
What budgeting skills does the young person have and have they ever been in total control of their personal allowance (above £30) how did they manage this?
What is the young person’s ambition for the next 6 months?
Please state your requirements for reporting this young person as a missing person?

WHAT ARE THE SERVICE USERS STRENGTHS

Please list below any areas in which the Service User demonstrates good functioning. Examples include:

Has at least one good family relationship
Personality Strengths (e.g. likeable, polite)
Ability to communicate feelings and wishes
Wants to live in a stable home
Enjoys and participates in one or more sports
Has one or more interests

WHAT IS THE STATUS OF THE SERVICE USERS EDUCATION AND EMPLOYMENT

Full-time education / Part-time education
Full-time employment / Part-time employment
Job Seeker / Not seeking work
Long term sick/disabled
Details (Where they work or attend college, what hours they work or attend college)

WHAT DO YOU KNOW ABOUT THE SERVICE USERS RELATIONSHIPS

Has there been any formal assessment of the Service Users relationships? If so please attach a copy of the reports.

Has a good relationship with at least one person in birth family
. Has an intense, but stable relationship with birth parent(s)
Avoids contact with birth family.
Exhibits extreme attention-seeking behavior
Exhibits immature regressed behavior
Fears rejection from care workers
Avoids close relationships
Can form and maintain friendships
Makes friendships but often looses friends
Socially isolated, doesn’t form or maintain friendships
Narrative:
Please describe any significant family relationships (if any) and an opinion about the quality of those relationships.

SUICIDE, SELF HARM, AND RISK TAKING BEHAVIOUR

Please provide details of any information ticked.

No information is known about self harm, suicidal or risky behavior
(if you ticked this box then proceed to the ‘’offending behavior ’; section)
Mild risk taking behavior usually only observed in company or peer group
(e.g. occasionally gets drunk with friends, comes home late from parties)
Intentionally causes injury to him/herself
Never mentioned or threatened suicide, and never attempted suicide
Has discussed and threatened suicide
Has attempted suicide
Details (e.g. dates results of attempts, what leads to attempts)

OFFENDING BEHAVIOUR IN THE COMMUNTIY

Please provide details of any information ticked.

No prior involvement with the police
Has had police involvement but no charges
Offences involving assault
Minor incidents of theft from family, friends
Regular or serious incidents of theft from family, friends
Offences involving destruction of property
Details (e.g. dates, offences, current court orders etc)

HAS THE SERVICE USER BEEN INVOLVED IN ARSON?

No prior involvement with the police
Has had police involvement but no charges
Offences involving arson
Details (e.g. dates, offences, current court orders etc)

SEXUAL BEHAVIOUR

Does the Service Users have any history of sexualised behaviour?
Details (e.g. dates, incidents etc)

HEALTH AND DISABILITIES

Specific medical condition
Medication taken
Specific disabilities
Any allergies
Learning Disabilities
Mental Health Problems
Details (provide information on medical conditions, medication taken, special support required because of conditions, effect such conditions have on day to day living etc)

SUPPORT NEEDED

Please tick all that apply

Budgeting/debt / Keeping appointments
Personal Safety / Personal Hygiene
Meal planning / Food preparation
Shopping / Household cleaning
Details

OTHER SERVICE PROVIDERS

Please list past and present agencies, involved with the Service User

In order for us to process your referral please ensure that you provide us with the funding arrangements for your young person

Funded Yes □ No □

Funded / Yes / No
Contact Name
Address for Invoices to be sent to:
E-mail Address
Purchase Order Number

If there are any additional comments you would like to make, or any other information you feel is relevant please attach this to the referral form.