Targeted Youth Support

Integrated Youth Support Services

Request for TYS Intervention

Please complete all sections and include as much information as possible about the young person and their family as failure to do so will result in the referral being returned. All referrals will be subject to a thorough verification process at a TYS panel. If you require any assistance to complete this form, please contact the Targeted youth Support Team on 01642 496008.

About the Young Person

Name: / Other names:
Address: / Ethnicity(please specify):
Telephone: / Mobile:
Date of Birth: / Age:
Gender: / Religion(optional):
Is the young person disabled?
If yes, please provide details:

Referrer Details

Name: / Agency:
Address: / Telephone:
Email:
What is your agency’s involvement with the young person and what work has been carried out?

Common Assessment Framework

Is a CAF already in place?
If yes, please attach and you only need to complete pages 4 & 5 of this referral. / If no, please complete this form as thoroughly as possible to prevent any further delays and any other assessment that may have been completed.

Educational Details

Name of School: / Main contact:
Is the yp attending full time? / Address:
Does the yp have a Statement of Educational Needs? / Telephone:
Is the yp receiving any additional support?
If yes please provide details:
Educational concerns? E.g- behaviour, attendance, etc
Access to see yp allowed in school time? Yes: No:

Please note: A School referral will require a copy of the yp’s school time table, indicating which lessons are appropriate to see yp. Also attach any attendance/behaviour records.

Other agencies involved with the family

Name of worker / Agency / Telephone / Details

Has there been any Social Care involvement with the referred young person or any others in the family?

Details……………………………………………………………………………………………………………………………………………………………………………

Family Details

Who holds parental responsibility for the young person?......

Please give details below of significant others ( including parents, carers, siblings, others living at home)

Name / Relationship / Date of Birth / Address / Telephone

Are there any risks associated with visiting this family/premises ( e.g. Drug users, dogs, known offenders)…………………………………………………………….

Outcomes

What outcome would the referrer and the young person like to achieve?

Consent of Young person and Parent/Carer

The young person and parent/carer should read and sign this to show they are happy for this referral to be made.

We consent to the referral to Targeted Youth Support being made and agree that we will support and be part of the agreed plan.
We also agree that information held by member agencies of the TYS Panel and obtained through the referral and assessment process, relating to the young person and their family may be shared with relevant agencies or organisations for the purpose of developing and implementing a Personal Support Plan.
Information may be shared with outside agencies for the purpose of evaluating the effectiveness of TYS. The sharing of sensitive information will be carried out in accordance with the terms and procedures of Redcar and Cleveland Borough Council Information Sharing Protocol.
We understand that this information will be stored either electronically or in manual records indefinitely by TYS and relevant TYS partners for case management purposes and to monitor and evaluate the success of the services.

Signatures required

Young Person / Date:
Parent/Carer / Date:
Referrer / Date:

Reason for Referral

Risk Factors- to be completed by referring Agency only.

Please tick any of the following risk factors which apply to this young person, you must provide evidence in the box below.

At risk of early disengagement from education? / At risk of crime/Anti Social Behaviour?
Is regularly absent from school
(authorised, sickness, family illness, lateness, young carer) / Lives in an area that is known for high crime and deprivation
Disruptive behaviour in school
(struggles to communicate, lack of confidence, anger issues) / Does not use spare time constructively
Receiving Pastoral Support
( behaviour, anger, bullying, struggling with school work, on school report) / Has friends who are involved in anti social behaviour
Finds current level of school work difficult
(lack of participation, lack of interest, de-motivated) / Has the yp come to the attention of the Police or ASB team?
Has received fixed term exclusions
(relationship with teachers, behaviour, attitude toward school) / Has received letter 1 or 2 from the Police
Involved in risk taking behaviour? / Has the yp entered the criminal Justice System
Substance misuse- Alcohol.
Units per week, approx? / Individual
Substance misuse- Smoking
Cigarettes per week, approx? / Does not adhere to set boundaries
(does not follow school rules, not returning home at agreed time)
Substance misuse- other drugs
(If known, please state) / Does not seem to understand the consequences of his/her actions
Teenage Pregnancy? / Acts impulsively most of the time
Lack of age appropriate friendships
(Hanging around with older peers being easily influenced) / Finds it difficult to control his/her temper
Under age sex
(Long term or short term relationship) / Is hyperactive/has poor concentration/ADHD
Promiscuous behaviour
(A constant exposure to 1 night stands or a high number of sexual partners) / Stable relationship with parent/carer
Please provide evidence to support each risk factor identified above;

Failure to sign this consent will result in the referral being returned.

Please send completed form to:

25k Youth & Community Centre

Ayton Drive

Redcar

TS10 4EW

Tel- Tel- 01642 496008

To be completed by TYS Lead at Panel meeting

What is the outcome of this referral, please tick below:
TYS/Agency follow up to offer support:
( state workers initials & specific tasks)
TYS proceed to a CAF
Referral rejected, please state reason
TYS Lead signature & date

TYS Referral Form

Up dated 22/08/11

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