Name: / Age: / DOB:
Address:
Post Code: / Gender: / Ethnicity:
Telephone No:
Mobile No:
(Mandatory)
Email:
(Mandatory)
Next of Kin Name:
Address:
Telephone No: / GP Name:
Address:
Telephone No:
Health Needs/Medication: / Additional Needs:
Disability Yes / No
Other workers/services involved:
Police Involvement YES/NO
Availability to attend:
Days: Times:
Preference:
Male / Female / Any Counsellor
1:1 Counselling/Group Counselling / School:
Contact Name:
Telephone No:
If we have a Base 25 counsellor at this school would you like appointments to take place there?
YES/NO / Current Destination:
Full Time School
Reduced Timetable
Full Time 6th Form/College
Part Time 6th Form/College
Higher Education
Full Time Employment
Part Time Employment
NEET
Brief details of how service may help:
Have you discussed this referral with the young person: Yes o No o
Does the young person wish to access the service: Yes o No o
Name of Referrer: / Organisation:
Address: / Telephone No:
Email Address:
(Mandatory)
Signed: / Date:
Service/s Referred to (please tick)
Key working / Base 25 Core Offer o
Anger Management Programme ...... o
(Under 16s – there is a charge for this service)
Counselling ...... o
Eastern European Community Development Work (EECDW) o
(There is a charge for this service)
EMPOWER ...... o
(Sexual Exploitation and Prevention)
Gangs Work...... o
(There is a charge for this service)
SAFE ...... o
(For work around negative behaviour choices
as a result of witnessing domestic abuse)
Young Men’s Work ...... o
(There is a charge for this service)
Young Women’s work...... o
(There is a charge for this service)
SS Community Feel Good (1-1 counselling) o
SS Safer Streets …...... o
For Office Use Only
Initial contact made by: ...... Date: ......
Outcome: …………………………………………………………………………......
......
......
Updated 2016
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