The WISH Centre Referral Form

REFERRER DETAILS: Date of Referral:......

Name: / Job Title:
Organisation: / Telephone Number:
Mobile Number: / Email Address:
Which programme are you referring the young person to? (tick all that apply) /  Safe2Speak - counselling for self harm, domestic violence, abuse or neglect
 Girls Xpress - Self harm Peer Support Group
 ISVA - Sexual Violence Counselling and/or Advocacy

CLIENT DETAILS:

Name: / Date of Birth:
Age: / Gender:
Telephone Number: / Email Address:
Address with Postcode:
Ok to contact Young Person directly? / YES / NO / Ok to leave a telephone message? / YES / NO
Alternative/Safe Emergency Contact Details(Tel/mobile)……………………………………………………
Have their parents/carers been informed of the Referral? Y/N
STATUS
School (Which one)……………………  College (Which one)……………………….
Government training  Full-time work
Part-time work  Long term Sick/Disabled
Unemployed  Asylum seeker
Refugee  Other …......
GP Name and Contact Details:

FAMILY COMPOSITION:

Name / DOB and Age / Relationship / Gender / Ethnicity / Religion / Disability
Main Address and Telephone Number if different from Client address: / Other significant Adults not living in the household;
LIVING WITH:ALONE / PARTNER / CHILDREN/ PARENT(S) /CARER(S)/ IN CARE/ RELATIVE(S) *delete as appropriate
REASON FOR REFERRAL/BACKGROUND AND INFORMATION: (tick any/all that apply)
Anxiety/Stress Suicide Ideation
Depression/Sadness Sexual Exploitation
Emotional Resilience difficulties Other (specify)......
Lack of Positive Coping Mechanisms
Trauma
Abuse
Self Harm
Notes:

CLINICAL/SUPPORT HISTORY:

IS THE YOUNG PERSON TAKING ANY MEDICATION (PLEASE SPECIFY IF KNOWN)? Y/N:
IF YES PLEASE GIVE DETAILS
DOES THE YOUNG PERSON HAVE A CLINICAL DIAGNOSIS (PLEASE SPECIFY)? Y/N:
IF YES PLEASE GIVE DETAILS
HAS THE YOUNG PERSON MADE ANY SUICIDE ATTEMPTS OR BEEN HOSPITALISED? Y/N:
IF YES PLEASE GIVE DETAILS
HAS THE YOUNG PERSON A RECENT HISTORY OF VIOLENCE OR AGGRESSIVE BEHAVIOUR TOWARDS OTHERS? Y/N
IF YES PLEASE GIVE DETAILS
ARE THERE ANY KNOWN ASSOCIATED RISKS E.G DOMESTIC/HONOUR-BASED VIOLENCE? Y/N
IF YES PLEASE GIVE DETAILS
IS THE YOUNG PERSON A CLASS A DRUG USER? Y/N
IF YES PLEASE GIVE DETAILS
IS THE YOUNG PERSON OR FAMILY MEMBERS ON A CHILD IN NEED PLAN? Y/N
IF YES PLEASE GIVE DETAILS.
IS THE YOUNG PERSON OR FAMILY MEMBERS ON A CHILD PROTECTION PLAN? Y/N
IF YES PLEASE GIVE DETAILS
IS THE YOUNG PERSON OR FAMILY MEMBERS INVOLVED WITH MARAC? Y/N
IF YES PLEASE GIVE DETAILS
INTERVENTIONS ALREADY COMPLETED
GP / A & E / HOUSING / CHILDRENS/SOCIAL SERVICES
DRUG & ALCOHOL / FORCED MARRIAGE UNIT / CAMHS REFERRAL / MENTAL HEALTH TEAM
PLEASE NAME ANY OTHER ORGANISATIONS OR WORKERS INVOLVED IN THE CLIENTS WELFARE:
PLEASE LIST ANY FURTHER INFORMATION OR ISSUES RELEVANT TO THIS REFERRAL:

Thank you. Please also complete the Equal & Diversity form, and ISVA form (If relevant) and email to or post to us. Once we receive the referral form we will make contact directly with the young person, if appropriate, or with the referrer within 10 working days in order to discuss their needs further and arrange a first appointment with us.

To be completed for Sexual Violence (ISVA) Referral Only

DETAILS OF LAST INCIDENT (if known)
TYPE OF ABUSE (please tick all relevant fields): / RAPE / CHILDHOOD SEXUAL ABUSE
PROSTITUTION / SEXUAL BULLYING / SEXUAL HARASSMENT
SEXUAL EXPLOITATION / GANG RELATED SEXUAL VIOLENCE
OTHER RISKY SEXUAL BEHAVIOUR (PLEASE STATE) :
INCIDENT NUMBER (if known): / DATE OF ASSAULT:
REPORTED TO THE POLICE: / YES / NO / INCIDENT LOCATION:
POLICE DIVISION/AREA: / INVESTIGATING OFFICER AND JOB TITLE:
CONTACT NUMBER: / EMAIL ADDRESS:
AGE OF PERPETRATOR AT TIME OF ASSAULT: / RELATIONSHIP OF PERPETRATOR
TO CLIENT:
BAILED / CUSTODY / UNDETECTED / DROPPED *delete as appropriate
TIME & DATE OF FORENSIC EXAM:
DETAILS OF HISTORICAL INCIDENT (IF RELEVANT)
TYPE OF ABUSE (please tick all relevant fields): / RAPE / CHILDHOOD SEXUAL ABUSE
PROSTITUTION / SEXUAL BULLYING / SEXUAL HARASSMENT
SEXUAL EXPLOITATION / GANG RELATED SEXUAL VIOLENCE
OTHER RISKY SEXUAL BEHAVIOUR (PLEASE STATE) :
INCIDENT NUMBER (if known): / DATE OF ASSAULT:
REPORTED TO THE POLICE: / YES / NO / INCIDENT LOCATION:
POLICE DIVISION/AREA: / INVESTIGATING OFFICER AND JOB TITLE:
CONTACT NUMBER: / EMAIL ADDRESS:
AGE OF PERPETRATOR AT TIME OF ASSAULT: / RELATIONSHIP OF PERPETRATOR
TO CLIENT:
BAILED / CUSTODY / UNDETECTED / DROPPED *delete as appropriate

EQUALITY AND DIVERSITY MONITORING (ALL REFERRALS)

ETHNICITY OF YOUNG PERSON:
WhiteAsian or Asian British
British Indian
Irish Pakistani
Any other White Background…......  Bangladeshi
Mixed Any other Asian Background …......
White and Black CaribbeanBlack or Black British
White and Black African Caribbean
White and Asian African
Any other Mixed Background …......  Any other Black Background …......
Chinese
Arab
Traveller
Any Other Ethnic Group …...... / RELIGION:
Baha'i
Buddhism
Christianity
Hinduism
Islam
Jainism
Judaism
Sikhism
No Religion
Prefer not to say

CLIENT DISABILITY:If a client considers themselves to have a disability please select the most appropriate definition. If the client has multiple disabilities please select the definition that reflects the predominant disability.

Not Considered Disabled / Physical Impairment / Mobility
Visual Impairment / Hearing Impairment / Long Standing Illness or
Health Condition
Learning Disability/Difficulty / Mental Health Issues / Did not wish to disclose
Unknown
Other (please state):

Gender : ………………………………………………

Age : ……………………………………………......

Sexuality (if known) : ……………………………...

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