CHILDREN AND YOUNG PEOPLE’S Me2 OUTREACH

Support for children who have lived with domestic violence abuse

Referral Form 2012

The Information recorded on this referral form will be treated with the strictest confidence and stored in accordance with the Data Protection Act 1998.

NB: PLEASE PROVIDE AS MUCH INFORMATION AS IS AVAILABLE TO YOU. CHILDREN MUST BE BETWEEN 4 AND 18 YEARS OF AGE TO RECEIVE SUPPORT.

*PLEASE COMPLETE A FORM FOR EACH CHILD SEPARATELY*

How did you hear about Me2 Outreach

Date of referral

Name of person putting child forward:

/

Relationship to child:

Address /Tel. No:

Email Address:

Child’s Name

Parent/ carer’s name

Child’s date of Birth: / Age: / Gender: / Ethnic background:
Address (incl. post code)
Tel. Number
Email address
School name
/
School Year
School teacher
School number
Who is currently living with child?
Is the child aware of the referral? / Yes
No
Are the parent(s)/carer(s) aware of the referral? / Yes
No
Is the child/young person still in the situation? If they are not how long have they been away from the situation?
How long did the abuse last or is it still continuing?
When was the last incident that the child/ young person was exposed to?
What abuse has the child been exposed to? (Tick all that apply and expand in the box below)
Physical abuse / Sexual abuse
Emotional abuse / Financial abuse
Forced marriage
Pleasedescribe what abuse the child/ young person has witnessed (for example was the child(ren) present? How did they react? Do they talk about the abuse?
Has the child got a CAF or is part of a TAC?
Who is the lead professional of the CAF?
Is the child on the child protection plan/are there safeguarding issues?
Are there any other agencies currently involved re: social worker, school mentor, CAMHS, YOS, PSA or MOSAIC?
Name of alleged perpetrator of abuse:
/ Relationship to child:
What contact does the child/young person have with the perpetrator?
Living with perpetrator / Contact with perpetrator / Separated from perpetrator
Does this child/young person have any emotional/behavioural issues at present that relate specifically to the domestic abuse?
Is there any other relevant information or any additional support needs that may affect the priority rating of this referral?
If Fraser Competent/ Over 13 years of age: young person’s verbal permission/signature:
Please tell us a safe way in which the chid can be contacted, including contact details (e.g. parent/carer/ via a school/ referrer/ adult friend)

Please note: All referrals will be taken to our monthly panel meeting and put in order of priority.

Due to the high demand for this service, Children and Young People’s Workers will not be able to continue to provide support sessions if 3 sessions are not attended without an explanation for the child/ young person’s absence.

Please forward completed referrals to The Child Support Outreach Team, Charter House, Norbury Street, Stockport, SK1 3SH or email

If you are unsure whether to refer a child or young person, please contact 01614774271

Registered Charity No. 1079291