Barnardo’s Independent Visitor Service

Coventry & Warwickshire

REFERRAL FORM
PART 1- CHILD / YOUNG PERSON’S DETAILS

Date of Referral
Looked After by / Coventry 
Warwickshire / Placed / In City/County 
Out of City/ County 
Child/young person / D.O.B
Name: / Age
Placement Address: / Gender
Ethnicity
Religion
Post code:
Date placed above: / Disabilities:
Physical
Carer/Keyworker / learning
Name: / Behavioural
Other
Phone No:
Mobile No: / SEN / Yes No 
Social Worker / Legal status / S20  C.O. 
Name:
Phone No:
Mobile/direct line / Date
Accommodated
Email:
Care plan / LAC 
Fieldwork Team
Name & Address: / for next two years / Rehabilitation home 
Special Guardianship 
Leaving care 
Ratified by Court/LAC / Yes No 
Team contact No: / Placement
Fax No: / Type / Foster Care 
Kinship 
Residential 
IRO / Duration / Temporary 
Long term 
Name: / Condition / Settled  unsettled 
Phone No:
Email Address: / In Education: / Yes No 
Name of
C&WCRS Advocate / school/college:
Name: / Address:
Contact Name:
Phone number

Barnardo’s Independent Visitor Service

Coventry & Warwickshire

PART 2 - RISK ASSESSMENT

Name of young person: Date of birth:

Independent Visitors will be visiting with a child or young person on a 1:1 basis, once a month and taking them out in the local community, usually on a Saturday or Sunday.

Please give details of any risks/ hazards that the Service and Independent Visitor (Volunteer) need to be aware of.

RISK / Yes / No / Likelihood of Occurrence on an IV visit
Likely / unlikely / not sure
Challenging behaviour
Verbal Abuse
Violence
Self-harm
Attempted suicide
Inappropriate sexualised behaviour
Absconding
Fire setting
Arson with intent to danger life
Theft/burglary
Damage to property
Alcohol or solvent abuse
Drug use
Making unproven allegations
CSE
Domestic Abuse
Racist/Homophobic Hate Crime
Other (please specify)
If you have ticked YES to any of the above please give information below:
(if required use a continuation sheet)
Has this information been shared with the young person? / Yes / No
If no please stat reason:

Barnardo’s Independent Visitor Service

Coventry & Warwickshire

PART 3 - BACKGROUND AND HISTORY

Name of young person: Date of birth:

Does the child/young person know you are making this referral Yes / No

CONTACT:

  • Does the child/ young personhave contact with parents or person(s) with parental responsibility?

(If yes please give details of the type of contact, frequency and quality)

  • Does the child/ young person have contact with any siblings or other relatives? (If yes please give details)
  • Are there any areas/places that the child/young person should not go to with their IV: (If yes please give details)

REASONS FOR MAKING THE REFERRAL:

Please can you give a brief description of the reasons why the child/young person is in care and how they will benefit from having an Independent visitor? Please state why you are making the referral at this time.

Any other information to help us find a suitable volunteer for this young person?

(For example has the child/ young person asked for a particular type of person or expressed an interest in a particular activity?)

Barnardo’s Independent Visitor Service

Coventry & Warwickshire

PART 4 - MEDICAL & ACTIVITY CONSENT

Name of young person: Date of birth:

  1. MEDICAL CONSENT: In the event of an emergency I give my consent for the young person named above to receive emergency medical treatment.

YES / NO

  1. From time to time we hold group activities for Independent Visitors and their young people – Do you give consent for your child/ young person to participate in these joint activities?
    YES / NO
  2. All activities will be risk assessed and where appropriate due diligence checks will be done on venues/activity providers.
    Activities with Independent Visitors will be done on a1:1 basis.

Do you give consent for the C/ YP to take part in:

  • go to the cinema / theatre / concertYES / NO
  • go shopping YES / NO
  • go for a drink/meal together YES / NO
  • visit a local park / country house YES / NO
  • visit museum / castle / other attractionYES / NO
  • go ice-skating / roller skating YES / NO
  • go ten pin bowling YES / NO
  • watch sports YES / NO
  • play a game of non contact sport
    e.g. football/tennis/basketball etc.YES / NO
  • swimming at leisure centre / water parkYES / NO
  • go cyclingYES / NO
  • adventure / theme parks
    appropriate to age & abilityYES / NO
  • go fishing at local lake / river / canalYES / NO

Please include below any extra notes
(use continuation sheet if required) if there is anyadditional information that may be helpful regarding activities:

Please note that children/young people will be expected to contribute to the cost of the activities they do with their IV. The amount the volunteer can claim for their out of pocket expenses is limited and will not cover the cost of activities such as bowling, ice skating, cinema etc.

  1. The following activities are not normally considered appropriate to the IV relationship:
  • meeting the IV’s family/friends
  • visiting the IV’s home
  • playing contact sports
  • high risk activities e.g. paintballing/abseiling / horse riding / skiing etc
  • or other activities considered to have higher risk factors

Should any of the above activities be suggested and considered appropriate to the IV role for the young person named above, the Project will consult with the relevant professionals involved and specific consent from the responsible social worker.

  1. Has all of the above information been shared with the young person YES / NO. (If no please state reason)

AGREEMENT BETWEEN SOCIAL CARE & BARNARDO’S:

Successful matches are a combination of the social care worker and Barnardo’s Independent Visitor service working together to:
promote, support and encourage the befriending relationship between the young person and their Independent Visitor.

As part of the agreement we agree to the following:-

  • Barnardo’s to match a young person ideally with an Independent Visitor of their choice.
  • Social Care to provide all relevant information and update the project regarding any changes to the young person’s care plan,
    i.e. – changes in placement or social worker etc.
  • Barnardo’s will provide annual evaluation feedback from the young person to the responsible social worker.
  • Social Care and Barnardo’s will work together to promote the match between the young person and their Independent Visitor.

NAME:
(Person completing parts 1- 4 of this form)

STATUS:

SIGNATURE: DATE:

TEL NO:

Please return completed referral form (Parts 1 to 4) to:

Gail Pajak - IV Team Manager

Barnardo’s Independent Visitor Service – Coventry & Warwickshire

Unit 8, Albion Court, 92 Attleborough Road, Nuneaton, CV11 4JJ

Email: