Tel: 0330 303 6000

Email: /

Fax: 0116 2938078

Date: ………………………………………….. Referral taken by: ………………………………..

  1. REFERRERS DETAILS

Referrer’s Name: ………………………………………………………………….Position: ……………………………………………………………......

Agency Name & Dept.: ………………………………………………………….Name of Lead Professional (If Known): ….……………………………………………..

Referrer’s Address......

Contact Telephone Number: ……………………………………………….Email: …………………………………………………………………......

2. YOUNG PERSONS DETAILS

Forename: ……………………………Surname: …………………………..Date of Birth: ……………………… Age………..Male Female

Young Person’s Residential Address: ……………………………………………………………………………………………………………………………………….

……………………………………………………….. Postcode: ……………………………………………. Telephone Number: ………………………………………

Has the Young Person given consent to be contacted at the above address & telephone number? YESNO

Has the Young Person given consent to contact his/her Parent/Carer? YESNO

Disability/Special Needs: ………………………………………………………..Language Needs: …………………………………………………………

Is the Young Person a Looked After Child?
Is there substance misuse within the family? / YESNO
YESNO / Who? ......
3. SUBSTANCE USE
Please list all drugs used, in order of the ones that cause YP most problems:
Sub 1...... How much: …………………… How is itused: ...... How often: ………….Age of 1st use…………
Sub 2...... How much: …………………… How is it used: ...... How often: ………….Age of 1st use…………
Sub 3...... How much: …………………… How is itused: ...... How often: ………….Age of 1st use…………
Have you ever been ill, or suffered side effects through taking any drugs, what happened?
………………………………………………………………………………………………….
………………………………………………………………………………………………….
Have you ever shared any equipment to use drugs? (e.g. pipes/bongs/notes)
4. GP DETAILS
GP/Practice Name: …………………………………………………...... Address: ......
……………………………………………………….. Postcode: ……………………………………………. Telephone Number: ………………………………………
Has the Young Person given consent to contact his/her GP: YESNO
Is YP injecting? YES NO Has YP ever injected? YES NO
…………………………………………………………………………………………………. ……………………………………………………………………
5. ETHNICITY
White British / White Irish / White Other
White/Black Caribbean / White Black African / White/Asian
Bangladeshi / Pakistani / Indian
Black African / Black Caribbean / Black British
Mixed Other / Asian Other / Black Other
Chinese / Vietnamese / Somali
Other (please specify): / ………………………………………………………………
6. Accommodation
Living with Parent(s) / Supported Housing/Hostel / Children’s Home –LA
Family/Friends / Living Independently / YOI
Residential School / Foster Care / No Fixed Abode
Other (please specify):
7. Education
The Young Person is in:
School / College / Unemployment
PRU / Training
SEN / Employment / Other (please specify)

......

Is the Young Person Excluded from School? YESNO

8. ADDITIONAL INFORMATION

How would you describe the Young Person’s Mental Health?

......

Has a Common Assessment Framework (CAF) been completed for this Young Person?YES NO

If yes, please attach a copy with this referral if possible

Has a risk assessment been completed for this Young Person?YES NO

If yes, please attach a copy with this referral if possible

Please provide details of any risk issues and/or any other information that you think is relevant:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………......

9. OTHER PROFESSIONALS

Is the Young Person involved with or have an order or plan with any other agency?

YOS CAHMS/CSSS Social Services CSE agency Any Other Agencies

Please provide details plan, name of contact and contact details: ………………………………………………………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………………………………………………………..

Are there any other agencies involved with the Young person or their family?YES NO

If yes, please list the names of the agencies and contact below:

Name of Agency / Name of Keyworker/Lead Person / Contact Tel. No. & Email
10. METHOD OF CONTACT AND CONSENT

(Referrer please ensure that the Young Person is aware & consenting to this referral to avoid any unnecessary delays in accessing treatment.)

HAS THE YOUNG PERSON BEEN MADE AWARE OF AND CONSENTED TO THIS REFERRAL BEING MADE?YES NO

Would the Young Person like support for their parent/carer?YES NO

If yes please make a referral to the Parent & Family Service

Where does the Young Person wish to be seen?………………………………………………………………………………………..

Young Person’s preferred method of contact:

Letter Text Telephone CallTelephone Call Via referrer

(Mobile)(Home)

THERE IS A REQUIREMENT FOR THE REFERRER TO BE AVAILABLE AND MAINTAIN CONTACT WITH Turning Point THROUGHOUT THE TREATMENT EPISODE AND MAY BE REQUIRED TO ATTEND AN UPDATE SESSION WITH THE CLIENT OR ASSIST IN MAKING CONTACT WITH THE CLIENT

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