Referral Form For Young People Services

Date of referral:
Please indicate which service you wish to make a referral for:
Psychotherapy in schools :
(please indicate below which type of
psychotherapy in schools you request) / Individual Psychotherapy in clinic
1) One-to-one therapy
2) Group therapy

Please complete in as much detail as possible, providing supporting reports and assessments where available

Child details
Surname: / First name(s):
Date of birth: / Age: / Gender:
Please specify type of residence (e.g. residential care home):
Address including Local Authority :
Tel no.
Details of parents/ carers with whom the child is currently living with:
Name (1): / M/F / DOB
Relationship to child:
Name(2): / M/F / DOB
Relationship to child:
Address:
Local Authority:
Tel no. / Email:
Details of other children with whom the child is currently living with:
Name (1): / M/F / DOB
Relationship to child:
Name (2): / M/F / DOB
Relationship to child:
Name (3): / M/F / DOB
Relationship to child:
Name (4): / M/F / DOB
Relationship to child:
Please provide details of any other children:
Details of birth family (if different from above)
Mother’s name:
Address:
Tel no. / Email:
Father’s name:
Address (if different from mother’s):
Tel no. / Email:
Names and dates of birth siblings:
Names(s): / Date of birth(s):
Referrer details
Name: / Position:
Organisation:
Address:
Tel no. / Email:

Is the client aware of this referral? Y / N

Are the parents / foster carers aware of this referral? Y / N

Client support network / n.b. It is important to know who else provides support and to avoid duplication of services.
Name: / Position:
Address:
Tel no. / Email:
Name: / Position:
Address:
Tel no. / Email:
Name: / Position:
Address:
Tel no. / Email:
Name: / Position:
Address:
Tel no. / Email:
Name: / Position:
Address:
Tel no. / Email:
Name: / Position:
Address:
Tel no. / Email:
Ethnic Classification
White / Black/Black British / Arab or other ethnic group
British / Caribbean / Arab
Irish / African / Any other
Any other white background / Black British
Any other Black background
Asian or Asian British / Mixed / Status
Indian / White and Black Caribbean / Refugee or Asylum seeker?
Pakistani / White and Black African
Bangladeshi / White and Asian
Chinese / Any other mixed background
Any other Asian background
First Language:
Other means of communicating:
Reason for referral
If the client is a victim of abuse, please provide any witness statements or records of interview or other details, including relationship to alleged perpetrator. Continue on another page if necessary.
If the person is currently in school, do they have
Special Educational Needs (SEN)? / Yes / No / Don’t know

In addition to the classification of ‘special needs’ please specify level of disability

Level of learning disability
Please tick the relevant box
Yes / No / Don’t know
Does the person have a learning disability?
Has there been an official diagnosis of learning disability?
If yes, when?
What is the level of learning disability diagnosed?
OR
If there has not been an official diagnosis, what is the level of learning disability according to your understanding?
Borderline
Mild
Moderate
Severe
Profound
Please tell us any other relevant information on verbal / non–verbal communication skills:
Area of other needs
Please tell us about any other relevant diagnosis (e.g. autism, epilepsy, down’s syndrome, physical or sensory disability) Please describe how their disability impacts on their day to day life.
Please indicate whether any of the following apply to the child
Current / Previous / Never / Don’t know
Accommodation by voluntary agreement with parents (S20 Children Act 1989)
Subject to a Care Order
(S31 Children Act 1989)
Remand to LA Accommodation (S23(1) Children and YoungPerson’s Act 1969
His/her name has been placed on the Child Protection Register
His/her name has been placed on the Sex Offender’s Register
Any other referrals to or contact with Social Services
Any other Social Services involvement with siblings
The client has ceased to be looked after within the last 12 months
Any details including placement details (where applicable):
Abuse History
Has the client:
Been sexually abused (i.e. disclosed)? / Yes / No / Suspected / Unknown
Been physically abused? / Yes / No / Suspected / Unknown
If yes or suspected, what age was the client when physically abused? / 0-5 / 6-12 / 13-18 / 19-25
Been emotionally abused or neglected? / Yes / No / Suspected / Unknown
If yes or suspected, what age was the client when emotionally abused or neglected? / 0-5 / 6-12 / 13-18 / 19-25
Complete only where sexual abuse is known or suspected
Age when sexually abused / 0-5 / 6-12 / 13-18 / 19-25 / Not known
Duration of abuse / Under 6 months / Over 6 months / Not known / Single incident?
Ongoing?
Age of perpetrator at time of abuse / Child
(0-12 yrs) / Adolescent
(13-17 yrs) / Adult
(18+ yrs) / Contact?
Non contact
Sex of perpetrator / Male / Female / Number of perpetrators:
Relationship of abuser to victim, e.g father, grandfather:
Are there any other known/suspected abusers in the family?
Yes / No / Don’tknow
If yes, please say whom:
Has the client’s family being involved with Social Services before the current referral?
Yes / No / Don’t know
If yes, please say why:
Criminal history
Does the client have a known criminal history? / Yes / No
If yes, has the client ever been: / Prosecuted / Cautioned / Arrested
Please give details:
Offence / Date / Disposal (including cautions)
Have the criminal justice system been involved with the client in any other way? / Yes / No
Mental health
Are there any indications that any of the following apply to the client?
YesNoDon’t Know
Depression
Self-harm
Previous suicide attempts
Eating disorders
Anxieties/phobias
Sleep disorders
ADHD
Dementia
Other
Details (e.g. any other psychiatric diagnoses):
Is there any history of mental health problems or learning disability in the family?
Yes No
Details:
Medication
Is the child taking any medication? / Yes / No / Don’t know
Details:
Please indicate whether the following apply to the child at school:
Yes / No / Don’t know
Regularly absent for other reasons than truanting e.g. parental decision, illness or other
Bullied at school
Behavioural Issues
Does the client present with any significant patterns of behavioural issues (other than sexually abusive behaviour)?
YesNoDon’t Know
Inappropriate sexualised behaviour
Fighting/aggression
Bullying
Alcohol/drug abuse
Stealing
Damage to property
Fire setting
Cruelty to animals
Specified conduct disorder
Perpetrator of sexual abuse
Details:
YesNoDon’t Know
Other behavioural issues
Details:
Loss and Bereavement
Yes / No / Don’t know
Has the client experienced parental separation?
Has the client experienced a significant bereavement in their life (including friends, professionals, pets, neighbours, etc.)?
If yes, whom has the client lost and when did it happen?
Child’s history
Please give the history of any trauma or abuse, including details of offending history (if appropriate)

Please return the form to:

Respond

3rd Floor

24-32 Stephenson Way

LondonNW1 2HD

IN CASE OF INDIVDUAL PSYCHOTHERAPY IN CLINIC:

Before the professional meeting, please return also the signed referral requirements and financial responsibility form sent together with this referral form. Alternatively, you can also bring the signed form to the professional meeting.

Please note that the referral process will not continue until the referral requirement and financial responsibility form has been signed and received.

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