Referral Form & Registration

Name: / Title
Date of Birth: / Age: / Gender

Contact Information

Please do not leave any boxes in this section blank

Home Address / Emergency Contact Details / Registered GP and Practice Address
Tel:
Mobile: / E.C Tel: / GP Tel:
Does the young person agree to us contacting them at the above address? / YES / NO
If no, where do they wish the correspondence to be sent?
(Please enter full details, name, address and contact telephone number etc.)
Ethnic Category
/ White
A – British
B – Irish
C – Other White / Mixed
D – White & Black Caribbean
E – White & Black African
F – White & Asian
G – Other Mixed / Asian/Asian British
H – Indian
J – Pakistani
K – Bangladeshi
L – Other Asian / Black/Black British
M – Caribbean
N – African
P – Other Black / Other Ethnic
R – Chinese
S – Any Other
Z – Not Stated
Religion (if known)

Referral Questions

Does the young person know the referral is being made? / YES / NO
Is the young person willing to access the service? / YES / NO
Are there any other agencies involved with the young person? / YES / NO
Is the young person willing to be seen at Y-Smart Offices? / YES / NO
If no, please state where they would prefer to be seen
Does the young person have any of the following (please circle)?
Learning Disabilities NO/YES / Physical Disabilities NO/YES / Behavioural Difficulties NO/YES
If yes, please describe
Does the young person have a care status:YES/ NO
If YES, please state whether the young person is either: Looked after child  Child in need 
Does the young person have caring responsibilities that may impact on their ability to access services? / YES / NO
What has prompted this referral?
Could the young person pose any risk/concern to the practitioner / YES / NO
If yes, please describe
Has the young person specified any of the following?
Male Worker Only NO/YES / Female Worker Only NO/YES / Does not mind YES / NO

YOT Referrals ONLY

Please use tick box to indicate type of referral : VOLUNTARY  COMPULSORY
If compulsory, please specify the requirements of the order
PLEASE GIVE DETAILS OF SUBSTANCE USE ON THE REVERSE SIDE OF THIS FORM

Substance Use

Please give information on substance(s) used and how regularly

Education, Training & Employment

Is the young person involved in any of the following activities:
Full-time Education at School/College NO/YES / Training Programme YES / NO
Employment NO/YES / Other YES / NO
If other, please describe
Please indicate the young person’s availability to be seen by a Y-Smart worker:
(e.g. after school only between 4pm and 6pm)
Has a DAF been completed?
If yes, have you attached it to this referral?

When returning the referral back to us, please use the following options:

Email:Y-Smart address:Y-Smart Barbican House, 5 Barbican Close, Barnstaple, EX32 9HETel numbers:(01271) 388162(01271) 325500Fax: (01271) 388175

Referrers Information:(Please fill in all the following contact fields below):

Referrers Name: / Referrers Job Role:
Referrers address: / Referrers email address and contact telephone no:
First Referral
YES / NO / How did you hear about our service?

(Office Use Only)

Date Received: / Allocated Worker: / Date Allocated: