Copyright Youth Justice Board for Englandwales Version 2 May 2005

/ Referral and Screening:
Parents, Carers & Others /
Please contact GRIP for help in completing this form: 01772 531488
What is your name? / What is your address:
What is your relationship with the child?
Telephone No:
Child details / Name: / Other Names: / Male / Female
Address: / Home Telephone: / DOB:
Post-code: / Other Telephone: / Age:
Ethnic Classification (based on 2001 census) / Information not obtainable
White / Black/Black British / Asian/Asian British / Chinese/Other Ethnic / Mixed
British / Caribbean / Indian / Chinese / White/Black Caribbean
Irish / African / Pakistani / Any Other / White/Black African
Other White / Other Black / Bangladeshi / White/Asian
Other Asian / Other mixed
PREFERRED LANGUAGE (other than English): / RELIGION (optional):
Family Details: Who holds parental responsibility for the child? Mother Father Other – Details:
Mother / Name: / DOB: / Address: /
Father / Name: / DOB: / Address: /
Other Carer / Name: / DOB: / Address: /
Other Children in household / 1Name: / 2Name: / 3Name:
Age: / M/F / Age: / M/F / Age: / M/F
Relationship: / Relationship: / Relationship:
4Name: / 5Name: / 6 Name:
Age: / M/F / Age: / M/F / Age: / M/F
Relationship: / Relationship: / Relationship:
Educational Details / Name of School (or other educational establishment):
Address:
Main contact at school: / Telephone:
Has the child been in trouble with the police? YES NO DK
Has the child got an antisocial behaviour contract or antisocial behaviour order? YES NO DK
If Yes, Details
Details of any other agencies involved with child (where known) e.g. GP, police, educational welfare / Name: / Name: / Name:
Agency: / Agency: / Agency:
Telephone: / Telephone: / Telephone:
Details of Involvement: / Details of Involvement: / Details of Involvement:
Reasons to Refer a Child: Please place a tick next to each factor that is relevant to the child being referred
Family situation and where the child lives
Some children and families suffer from many problems that can influence the behaviour of a child. These can include a child being separated from their mother, father or both □ ; children can experience harsh discipline in their home (including smacking for example) □ ; children and families can live in homes that are quite deprived (e.g. not being able to afford heating in winter) □ ; parents can find it difficult to always know who their child is with and/or where □ ; families can experience accommodation problems (e.g. moving around a lot or being threatened with eviction) □ and family members can be involved with the criminal justice system themselves □.
School and education
Some children can become bored at school and start to get in to trouble. Others can get in to trouble because they are not in school. Some of the things that might cause this to happen are: the child does not have a school place organised □ ; the child very often stays away from school (either with or without the parents/carer knowing) □ ; the child finds it hard to keep up with the level of work at school (e.g. needs help with reading) □ ; special educational needs have been identified by the school □ ; the child does not seem to care about their school (e.g. does not take part in any school sports or other school based activities) □ and child has been accused of bullying in school □.
The area they live in and who they hang around with
Some children have friends who can lead them in to trouble and can get bored because there is not much for them to do where they live. Some signs that this may apply to the child being referred include: the area being known for its high crime rate □ ; lack of appropriate play activities in the area □ ; living in an area that is quite isolated (e.g. rural area with lack of public transport) □ ; child does not seem to make good use of their spare time (e.g. spending each evening hanging around in parks) □ ; child has many friends who appear to be older than them □ and they have many friends who are known to get in to trouble □.
Things relating to health
Some children do things that can make them physically ill and impact on their behaviour (e.g. getting drunk). Some things can also cause them to be upset and act out their worries in harmful ways. Some examples of these issues could include: the child being known to drink too much alcohol (e.g. until they are drunk) □, smoking cigarettes □ or taking illegal drugs □; the child believing that they have to drink, smoke or take drugs to get through the day □ ; the child having a condition that affects their day to day life (e.g. being diagnosed with ADHD (Attention deficit hyperactivity disorder) or tourettes syndrome) □ ; child has suffered from a death or other loss that still upsets them (e.g. death of a grandparent, dad leaving area) □; child seems to be suffering from emotional problems (e.g. is very withdrawn, has an eating or sleeping disorder) □.
What the child thinks about themselves, others and their behaviour
What a child believes and how they think about things can have a great impact on their behaviour. These beliefs and ways of thinking can be influenced by many things, including the home and school for example. Some beliefs and behaviour that may be troubling can include: not being able to trust others (e.g. believing that all adults will let them down) □ ; using discriminatory language (e.g. making sexist or racist comments towards others) □ ; believing that anything they do will turn out well or believing that nothing they do will work out (e.g. being over or under confident in their abilities) □ ; child does not believe that they are doing anything wrong when behaving badly □ ; the child does not seem to think things through before they do them □ ; child is known to give in easily to others (e.g. friends) □ ; child finds it hard to wait for things that they want (e.g. gifts or attention from a parent/carer) □.
Good Things
There are some things in a child’s life that will help them to stop behaving badly. These can include: Understanding that they have some problems □ ; having a good support network (e.g. from family and friends) □ ; child having some ambition and plans for the future □ and making good use of any spare time they have (e.g. playing sports or at a youth centre) □.
Please provide some examples of the sort of behaviour you are worried about:
Consent: from child and parent/carer for the referral to be made
We have had GRIP (Group Intervention Panel) initiative explained to us and we agree to a referral being made.
We also agree that information held by member agencies of the GRIP panel and obtained through the referral and assessment process may be shared with relevant agencies or organisations for the purpose of developing and implementing an Integrated Support Plan (ISP). Information will also be shared with outside agencies for the purpose of evaluating the effectiveness of the GRIP initiative both locally and nationally. The sharing of information will be carried out in accordance with the terms and procedures of the GRIP information sharing protocol and with the registration with the office of the Information Sharing Commissioner.
We understand that this information will be stored either electronically or in the manual records by GRIP for case management purposes. We understand that this will be for the length of the ISP and for () months following to monitor and evaluate the success of GRIP. GRIP will keep the information updated and notify all recipients of any changes to ensure corrections are made.
Parent/Carer: / Young Person:
Print Name / Print Name
Signature / Signature
Date: / Date:
Please return this form to: your nearest GRIP office, as detailed on the Safer Lancashire Website, or to
GRIP, 143-161 Corporation Street, Preston, PR1 2UQ
To be completed by GRIP
Is this referral suitable for the Group Intervention Panel? YES NO
Verifiers Name: / Signature: / GRIPReferral Number:
Date:

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