HARROW CHILDREN & YOUNG PEOPLE’S ADVOCACY SERVICE

REFERRAL FORM

SERVICE CRITERIA:
We provide independent advocacy support to young people aged between 7 and 25 years, who are subject to the following processes:
  • Child protection
  • Children in need (including children with a disability up to 25 years)
  • Care leavers
  • Looked after children
And:
  • Children who would like to raise a concern or complaint about social care services
  • Refugee and asylum seeking children
  • Young Carers
Please note the service is a child led and the child/young person needs to consent to this referral

REFFERAL PROCESS:

  • Advocacy is a child led relationship: please make sure you ask the young person for permission before you make this referral.
  • Young people can self-refer By email through our website telephone 0203 9480 559 or text 07483 106072
  • Email completed referral form either password protected or using Egress to

REFERRER’S DETAILS:

Date of referral:
Date of allocation:
Date opened by the advocate:
Name:
Job role or relationship to the young person:
Contact details:
  • Address:

  • Telephone & Email:

YOUNG PERSON’S DETAILS:

Name:
Date of Birth:
Age:
Telephone:
Address:
Email:
Has the young person consented to this referral / Yes /No

DETAILS OF PEOPLE WE MIGHT NEED TO CONTACT:

e.g. parent, carer, teacher.
Name:
Job role/relationship to young person:
Contact details:
  • Address:
  • Telephone & Email:

Name:
Job role/relationship to young person:
Contact details:
  • Address:
  • Telephone & email

ELIGIBILITY CRITERIA:
Please select those that apply to the young person.
PRIMARY STATUS OF YP
Child Protection
Child in Need
Care leaver
Looked After Child
Young Carer
Young person wishes to complaint / raise issues about social care
ADDITIONAL STATUS OF YP
Refugee and Asylum Seeker
Young offender
Young Person has a disability
DETAILS OF PLANNED MEETINGS:
Description / Purpose of meeting:
Date:
Time:
Venue:
Notes:
DETAILS OF FOLLOW UP MEETING:
Description / Purpose of meeting:
Notes:
INFORMATION RELATING TO THE REFERRAL
Please tell us why you are making this referral: Take care to only provide information that can be freely shared with the young person.
Notes:

FURTHER INFORMATION

Please tell us about any risks in working with the child or young person you feel we need to know about
Notes:

EQUALITY MONITORING DATA

Please tick the description within each category that best describes the young person.

AGE RANGE

7-11
12-16
17-21
22-25

GENDER

Male
Female
Transgender

SEXUAL ORIENTATION

Unknown or young person is under 16
Heterosexual
Bisexual
Gay Man
Gay Woman / Lesbian

DISABILITY

Physical disability
Deaf / hard of hearing
Blind / visual impaired
Learning difficulty
Mental ill - health
Multiple disabilities
Unknown

ETHNIC ORIGIN

ASIAN OR ASIAN BRITISH
Afghani
Bangladeshi
Chinese
Indian
Pakistani
Sri Lankan
BLACK OR BLACK BRITISH
African
Caribbean
Somali
MIXED BACKGROUND
White and Black African
White and Black Caribbean
White and Asian
OTHER ETHNIC BACKGROUND
Arab
Iranian
WHITE OR WHITE BRITISH
Albanian
English
Gypsy / Irish Traveller
Irish
Polish
Romanian
Scottish
Welsh
Other ethnicity, please specify:

RELIGION & BELIEF

Buddhism
Judaism
Christianity (all denominations)
Sikh
Hinduism
Islam
Jainism
No religion / Atheist
Zoroastrian
Other – please specify:

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