Office use only:

Date referral form processed following incomplete referral
Pending closure date following no contact from YP
Client ID

42nd Street Referral Form 2016 - for Professionals

(referrals for young people 13+ years)

Has this referral been discussed with and agreed by the young person?

Yes / No

Has the young person previously been referred to 42nd Street?

Yes / No / Unknown
Date of Referral

YOUNG PERSON’S INFORMATION:

Title / First Name / Surname
Age / Date of Birth
Male / Female / Trans / Other - please state

Gender:

Area of Residence:

Manchester / Tameside & Glossop / Trafford / Salford

Young Person’s Contact Details:

Address line 1
Address line 2
Town
Post code
Telephone (1)
Mobile
Email

Permission to Contact Young Person:

Ok to post mail to young person? / Yes / No
Ok to phone Telephone (1)? / Yes / No
Ok to phone mobile? / Yes / No
Ok to text young person? / Yes / No
OK to leave a voicemail? / Yes / No
OK to email young person? / Yes / No
Preferred way for us to contact young person? Please state
Yes / No

Is the GP the Referrer?

GP Details:

Name of GP
Name of GP Surgery
Address
Post code
Phone Number
Email
Not registered with a GP (Please tick)

Referrer Details:

Name of Referrer
Referrer Job Title/Role
Name of Referrer Organisation
Address
Post code
Phone Number
Email

Referrer:

GP / Local Authority
IAPT Service / Hospital (inpatient services)
School nurse / A+E
Gateway / Early Help Hubs / Bridge / Local Authority single point of access service / Youth Offending Service
Early Identification of Psychosis services / Youth Justice Organisations
Bereavement services / Probation
Voluntary sector (drugs/alcohol): service (Please state name) / Prison
Voluntary Sector (mental health) – (Please state name) / Police
Voluntary Sector (social care) – (Please state name) / Hostel / Supported accommodation
Crisis Services / Job Centre, employment support agencies
CSE services / School (name)
Arts organisations / PRU/Alternative education
SureStart / FE Colleges
Youth and community groups / HEIs, including university counselling services
Statutory Social Care / Advocacy organisation
CAMHS / Advice Centre – legal, financial.
AMHS / Victim Support
Early Help Service: (please state name) / SARC
Eating Disorder Service / Refugee/ asylum support services

REFERRAL INFORMATION.

Can you tell us briefly about the difficulties / experiences which affect the young person’s mental health or emotional well-being?

Please tick any difficulties/experiences that apply.

Bullying / Anger
Discrimination e.g. religious, homo/trans/biphobia, disability, racism / Exam stress
Loneliness / isolation / Cultural issues
Homeless / at risk of homelessness / Refugee or seeking asylum
Anxiety (social anxiety & phobias) / Confidence / self-esteem
General Anxiety / Stress / Worry / Health worries / concerns
Obsessive Compulsive Disorder (OCD) / Bereavement
Panic attacks / Disability
Avoids going out (agoraphobia) / Physical Health
Depression / Domestic Violence
Self-harm / Eating disorder
Suicidal thoughts / Sexual abuse
Suicidal attempts / Physical abuse
Risk to others / Emotional abuse
Post-traumatic stress / Neglect
Psychosis (Paranoia, Hallucinations, schizophrenia, etc.) / Ritual / honour based violence e.g. Female Genital Mutilation (FGM)
Extreme of mood - bipolar / Sexuality
Family problems / Gender identity
Attachment issues / difficulties / Miscarriage or Termination
Friendship difficulties / Sexual health concerns
Other relationship difficulties / Self-care issues
Persistent relationship issues (includes Personality Disorders) / Drug / alcohol misuse (own)
Challenging Behaviour
Please give details:

Can you tell us why the young person would like to come to 42nd Street for support?

Please give details:

What types of support or activities is the young person interested in at the moment?

Individual therapeutic support: includes counselling; Cognitive Behavioural Therapy (CBT); one-to-one support; and advocacy.
Creative and group work programme includes arts, identity, therapeutic, issue based groups and social action projects.
Both of the above
Not sure

If you would like to know more about 42nd Street, our individual therapeutic support or creative and group work programme, you can find more information on our website www.42ndstreet.org.uk or you can call us on 0161 228 7321.

Does the young person’s behaviour ever present a risk to them self or others?

Does the young person present any risk to others? / No / Yes
Does the young person self-injure or self-harm? / No / Yes, often
Yes, sometimes / Prefer not to say
Do they have suicidal thoughts? / No / Yes / Prefer not to say
Have they attempted suicide? / No / Yes, Once / Yes, more than once
Yes, in the last 6 months / Prefer not to say
Has the young person had any thoughts of suicide in the past 6 weeks that they have wanted to act upon? / No / Yes
Please give details:

Are there any other issues about their mental health that it is important for us to know at this stage: e.g.: physical health difficulties; medication prescribed by a doctor/psychiatrist; other crisis or risk issues, a formal diagnosis from a GP or Psychiatrist.

Please give details:

Is the young person receiving support from any other professionals or services?

e.g. social worker; psychiatrist; psychologist, etc.

Yes No

Please give details:

Does the young person have any particular needs we need to be aware of when we contact them or offer them an appointment?

Please give details:

Appointment Preferences:

*Please be aware that preferences are not always available* Last available appointment 6.00pm at our office base on Mon, Tues, Wed & Thurs; 4pm on Fridays.

Appointment time: / Day / Evening / Either
Preferred worker gender: / Male / Female / Either
Preferred Project Type: / ‘Inside Out’ (LGBTQ+) / Disabled Young People’s project

Please tick if the young person needs a community based appointment

Please tick if the young person has had a previous referral to 42nd Street

Young Person’s Identity Information

Ethnicity:

White- British / Asian or Asian British- Pakistani
White- Irish / Asian or Asian British- Bangladeshi
Any other White background / Any other Asian background
Mixed-White and Black Caribbean / Black or Black British- Caribbean
Mixed-White and Black African / Black or Black British- African
Mixed-White and Asian / Any other Black background
Any other mixed background / Chinese
Asian or Asian British / Any other ethnic group
Asian or Asian British- Indian / Prefer not to say
Not Disabled / Multiple disabilities
Physical disability / Unseen/invisible disability e.g. epilepsy, asthma etc.
Blind/partially sighted / Asperger’s/ autism
Deaf/hard of hearing / Other
Learning disability/difficulty / Prefer not to say

Disability:

Young carer for a parent/carer or family members:

Yes / No / Prefer not to say

What Happens Next?

We will contact the young person to arrange an initial assessment and confirm the arrangements in writing. We will notify all referrers of the young person’s engagement with our service.

If you have any further questions regarding our services, please get in touch on 0161 228 7321.

If you would like more information regarding data protection or our confidentiality policy, please visit our website: www.42ndstreet.org.uk.

When you have completed this form please send it to us by post or fax.

42nd Street, The Space, 87 – 91 Great Ancoats Street, Manchester, M4 5AG

FAX: 0161 228 0528

OFFICE USE ONLY:

Outcome of Referral:

Admin: Referral entered onto database: / Admin Initials: / Date:
DUTY: Referral Screening
Outcome: / Not accepted / (Tick): / Disengagement Form complete and sent to Admin (Yes):
Admin: Disengaged on database (Tick):
DUTY: Referral Screening
Outcome: / Accepted
(Tick relevant route) / IM / Geographical Text (No-reply) confirmation of referral acceptance/will contact to book IM (Tick)
Urgent Case Management
Group only / Group name:
Engagement Worker: Referral entered onto general waiting list / group specific waiting list: / Initials: / Date:
Engagement Worker: Unable to speak to YP to offer an IM appt. / Following contact attempt to book IM / no response - text to yp (2 week reply window) (Tick) / No reply after 2 weeks, close case and letter sent to referrer saying no service required. (Tick)
Engagement Worker:
IM Booking / Date and time of IM: / IM worker name: / Appt letter sent to confirm (tick)

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