Please Note That All Fields Marked * Must Be Completed

Independent Visitor Referral

Please note that all fields marked * must be completed.

Independent Visitors are unpaid volunteers who will befriend and taking a long term interest in a young person. An Independent Visitor will visit the young person weekly/fortnightly and take them out into the community to engage in social activities. The expected outcomes for the young person are an increase in confidence, resilience and social inclusion.

An Independent Visitor is NOT an advocate.

It is a statutory requirement that children and young people in care who would benefit from an Independent Visitor are offered one at their review meeting. These volunteers are trained and supervised by Barnardo’s.

REFERRAL CRITERIA

A child or young person is eligible for an Independent Visitor if:-

·  They are aged 0-18 (up to 24 years if they have a disability)

·  They are in care

·  They do not have regular contact with their birth family (more than once a month is considered regular contact)

Child or Young Person Details
Last Name: * / Date of Birth:*
First Name:* / Gender: * / Please SelectMaleFemaleTransgender
Other Names: / Ethnicity: * / Please Select...White - BritishWhite - IrishWhite - OtherMixed - White/ British CaribbeanMixed - White/ British AfricaMixed - White/ AsianAsian/ British - IndianAsian/ British - PakistaniAsian/ British - BangladeshiAsian/ British - OtherBlack/ British - CaribbeanBlack/ British - AfricanBlack/ British - OtherOther ethnic groups - ChineseOther ethnic groupsNot stated by individualUnknown
Disability: * / Please SelectNoneData being SoughtAutism Spectrum ConditionBehaviourall based DisabilityCommunication impairmentComplex Sensory ImpairmentComplex Needs excluding invasive CareComplex Needs including invasive CareHearing ImpairmentLearning DisabiltiyMental Ill Health lasting more than 12 monthsPhysical ImpairmentSight ImpairmentPrefer Not to Say
Placement address line 1* / Preferred Language:
Address line 2 / Second Language:
Town * / Religion: * / Please SelectAnglicanAtheistBaptistBuddhistCatholicChurch of EnglandChurch of ScotlandChurch of WalesHinduJohovah's WitnessJewishMethodistMormonMuslimNon Practising ChristianOtherOther ChristianPentecostalPrefer Not to SayProtestantRastafarianData being SoughtNone Practised
County / Any contact with family? * / Please SelectYesNo
Postcode * / CP Registration Status/Plan: * / Please select...CurrentHistoricalUnknownNone
Looked after child: * / Statement of SEN:
Carer Details
Name(s): * / Contact No(s): *
Additional information (e.g. address, if different from above):
School Details
Name & Address: / Contact name:
Phone no:
Social Worker making referral Details
Name: * / Phone No: *
Office Address / Email :
Local Authority with legal responsibility for the child/young person
Legal Status of the Child/Young Person
Is the child in care? Please select...YesNo / Is the child ex child in care? Please select...YesNo
Is the placement out of county? Please select...YesNo
How frequent is family contact? Please include visits and other forms of communication and contact
Date of Review when the need for an Independent Visitor was agreed (if applicable)
Other agencies involved
Education / Key worker / Health / Key worker / CAMHS / Key worker / Other / Key worker
Reason for making referral – We will talk to the young person and their social worked about desired outcomes for the young person
Please give details of the child/young person’s disability and/or related complex needs:-
(risk assessment and further discussion with social worker will follow)
Please comment on fluency in English or other languages:
Chosen language Second language
Does the child/young person have any special requirements relating to health & safety/risk/mobility, communication, etc?
If yes, please give details
Information on the child/young person
How long has the child/young person been looked after?
What is the length of time they have spent in their current placement?
Is another move planned or likely?
If yes, please provide details
Has this referral been discussed with the child or young person?
If yes, please provide details
Ideally, after discussion with the young person, or in your opinion, please provide an indication of the type of ‘IV’ that would suit the young person relating to skills, gender and likes/dislikes
Are there any safety issues for workers making contact with the referred child/young person?
If you wish to share any other information which is relevant to this referral, please do so below
Name of Social Worker Date of referral

Return to:

Project Worker: Verity Walker - 07825 414112

Administrator: Lynne Smith - 07896 717025

Version July 2014 Registered charity 216250 and SCO37605