Streetwise CYP One-to-One Referral Form

The Children’s Society – Streetwise Coventry Eaton House, 2nd Floor, 1 Eaton House, Coventry, CV1 2FJ Tel: 02476 230 060 Email:

childrenssociety.org.uk / Streetwise Coventry / 08/12/2016 / 1
childrenssociety.org.uk / Streetwise Coventry / 08/12/2016 / 1

The Children’s Society’s Streetwise Project delivers preventative work and support to young people (aged 11-18 years old) who are at risk of being sexually exploited. We raise awareness of the dangers of grooming and cyber-grooming and support young people to stay safe.

Name of Referrer:
Agency: / Address:
Tel: / Email:
Referral method: / Date:
Name of young person:
Address: / Tel:
Is the young person aware of this referral?
Date of birth: / Gender:
Ethnicity: / Does the young person have a disability? (please give details)

Reason for Referral

Please give background information and reason for this referral. Please identify your major concerns, which may include substance misuse, domestic abuse, inappropriate sexual behaviour, mental health, etc. Please include positive factors and strengths.

Other agency involvement

Name: / Agency / Address: / Tel no:
Has a CAF been completed? Yes / No / If Yes, who is the Lead?
Is the young person subject to CIN, CP or LAC plan?
Has there been any historical social care involvement?
Yes/ No / Please provide details
Has a CSE screening tool been completed (please attach)? Yes/ No
What was the result?
Has a MASE meeting been held? / Please provide details
Has the young person been discussed at COG or MOG?
What school does the young person attend?
What is their attendance rate? / Please provide details:

Risk Indicators

(Please tick all that apply and provide evidence)

Health
Symptoms of physical abuse / Evidence:
Recurring STIs
Evidence of drug, alcohol or substance misuse
Sexually risky behaviour
Education
Truancy / disengagement with education or considerable change in performance at school / Evidence:
Family and social relationships
Persistently missing, staying our overnight or returning late with no plausible explanation / Evidence:
Hostility in relationships with parents/ carers, siblings, pets, teachers, peers, and / or other family members
Reports from reliable sources (e.g. parents / carers / other professionals) suggesting the likelihood of involvement in sexual exploitation
Associating with other young people who are known to be sexually exploited
Detachment from age-appropriate activities
Adults or older young people loitering outside the young person’s usual home
Sexual relationship with a significantly older person or unexplained relationship with older adults
Possible inappropriate use of the Internet and forming relationships, particularly with adults, via the Internet
Phone calls, text messages or letters from unknown adults
History of physical, sexual and / or emotional abuse or neglect, domestic violence
Social presentation
Change in appearance / Evidence:
Possession of large amounts of money with no plausible explanation, Acquisition of expensive clothes, mobile phones or other possessions without plausible explanation
Reports that the young person has been seen in places known for sexual exploitation
Additional risk indicators for boys and young men
Sexualised language / Evidence:
Anti-social behaviour
Sexually offending behaviour
Possession of abnormal amounts of money, gifts, new mobile phones, credit on mobile phones, number of SIM cards
Seen at public toilets known for ‘cottaging’ or adult venues (pubs, clubs, etc)
Emotional and behavioural development
Volatile behaviour exhibiting extreme array of mood swings or use of abusive language / Evidence:
Getting involved in petty crime, such as stealing, shoplifting, etc
Secretive behaviour
Entering or leaving vehicles driven by unknown adults
Identity
Low self-image, low self-esteem, self-harming behaviour, e.g. cutting, overdosing, eating disorder, promiscuity / Evidence:
Any other information (please include any risks to a worker)?

For internal use only

5 or more (low) / Decision / Reason:
10 or more (medium)
15 or more (high)
childrenssociety.org.uk / Streetwise Coventry / 08/12/2016 / 1