The Children’s Society in London

Havering Advocacy Service

Referral Form

Initial Information:
Date: / Call/emailreceived by:
About the person making the referral:
Self-Referral:
Parent/Carer’s name: / Parent/Carer’s telephone:
Professional’s name and relationship to YP: / Professional’s email:
Agency address: / Agency telephone:
About the Child / Young Person:
Name:
Date of Birth:
Age:
Gender:
Ethnicity: / Preferred Language:
Is English the first language? / Is English the second language?
Does the young person consider themselves disabled? / Details:
Home address and Postcode:
Home telephone no/mobile no(indicate preferred contact method):
School: / School Year:
Is there any SENCO involvement – if so please name contact? / Learning Mentor/Teacher:
Head teacher: / Phone No:
About the Child / Young Person (continued):
Name of Person(s) with Parental Responsibility:
Under which Order is the Young Person accommodated?
Are they willing to sign Consent Forms?
Are they aware of and have they requested the Initial Referral?
Is there anything we should know about this Young Person that may pose a threat/risk to themselves, others or the Worker allocated by The Children’s Society?
Agency involvement:
Please give details of any other service involved including Police, Social Services, Health, CAF/EHA and Youth Offending Service: need to include nature of involvement i.e. CP register, ASBO etc.
Agency / Contact name and details /
Notes
Looked After
(include SW and IRO)
Child Protection Plan
Child In Need
CAF/EHA
Health
In Trouble With the Law
Other
Brief history and reason for referral and any important meeting dates:
Complaint / Initial Child
Protection
Conference / Child Protection Review / LAC review / Transfer Conference / Family Group Conference / Child in Need Meeting / Early Help Assessment/CAF
Family Court / Other
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Signed:………………………………………………………………(NAME)……………………

For The Children’s Society’s use:

Referral No:

Case No (if accepted after referral):

ACTION PLAN / REFERRAL
Referral eligible?
Agency signposted to: / Date: / By:
Placed on waiting list?
Allocated to: / Date:
Referral acknowledgement letters sent: / Date: / By:
Initial assessment completed: / Date: / By:
Assessment of risk / need completed: / Date: / By:
Policies Explained / Signed / Date
Consent
Confidentiality
Safeguarding
Data Protection
Complaints & Compliments
Equal opportunities
Checklist / Signed / Date
Referral entered onto CHYMS
CAF/EHA check complete
Children’s Services check complete

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