This document has been classified as: Restricted

South Tyneside Youth Justice Service

38 LAYGATE PLACE, SOUTH SHIELDS, NE33 5RT – TEL: 0191 4272850

REFERRAL ORDER CONTRACT

Young Person / DOB
Address / Postcode
Ethnicity /

Religion

/

Gender

Phone/Mobile
Length of Order / Date Order Imposed
ETE Details
GP / Medical Centre
Dental Practice
Medication / Allergies
Other Health
Parent/Carer
Address
(If different from above)
Phone/Mobile

THIS FORM IS AVAILABLE IN OTHER LANGUAGES ON REQUEST

Part A: COMPULSORY

1.  I will attend all future Panel Meetings.

2.  I will attend the following appointments per month. The number of appointments may change depending on my progress, my assessed risk of offending or my risk to others.

Level / Minimum for first 12 Weeks / Minimum after 12 Weeks / P
Standard / 2 / 1
Enhanced / 4 / 2
Intensive / 12 / 4

3.  I will carry out work with my supervising officer to reduce the risk of offending by:

a)  (Add targets as appropriate)

4.  To make amends for my offence I will:

a)  (Add targets as appropriate)

(Delete as appropriate)

5.  I will meet with a member of staff to assess my education/training and employment needs and agree that if further appointments are recommended then I will attend these.

6.  I have given my consent to undertake work with the Matrix to address my Substance Use. The number of appointments to be agreed after an initial assessment.

7.  I will undertake 8 x 1 hour sessions of Drug and Alcohol Educational work.

Part B: VOLUNTARY

8.  I will undertake the following on a voluntary basis:

a)  Provide the YJS with feedback about the services I have received.

b)  (Add targets as appropriate)

Part C: FAILURE TO COMPLY

This contract is legally binding and failure to comply with it may result in you being returned to court.

You will receive warning letters for any missed appointments. If you have received 2 warning letters and then miss a further appointment, you will be returned back to panel and a decision will be made whether or not to return you to court.

If your YJS Officer assesses that there is a single ‘serious’ unacceptable failure to comply then you can also be returned to panel.

By signing this I confirm that the ‘Instructions for Supervision’ and ‘Additional Information’ have been fully explained to me and I confirm that I understand these.

NB: Young people aged 15y and under require parental signature for health services

SIGNED:

______

Young Person

______

Parent/Carer

______

Panel Leader (on behalf of South Tyneside Youth Justice Service)

DATE AGREED:______

Part D: FIRST APPOINTMENT

My first appointment as part of my Referral Order is:

DATE/TIME/PLACE:
WORKER:
TO DO:
INSTRUCTIONS FOR SUPERVISION
You must:

1.  Tell your Supervising Officer if you change your address or employment

2.  Attend all appointments on time. If you cannot attend you must tell the YJS before your appointment

3.  Receive home visits

4.  Cooperate fully in your supervision plan

5.  Comply with Health & Safety Instructions given to you by YJS staff

You must not:

1.  Commit any further offences

2.  Use violent, aggressive, offensive or threatening language or behaviour towards any person

3.  Do anything to obstruct your supervision or the supervision of other young people

If you fail to comply with any of the above then you will face being taken back to court

Health: As part of your order you will be offered services to promote your health. We need your consent for this. Please tick if you do not want;

§  To receive a General Health Assessment 5

§  Intervention from the Matrix Substance Misuse Service 5

§  The YJS Health Worker to access your health records; 5

Including Learning Disability & Mental Health records if required

ADDITIONAL INFORMATION

Sickness Policy: If you miss appointments because you’re ill then you need to complete a ‘sickness form’. If you are ill again within 3 months, a Doctors sick note is required.

Transport: Public Transport journeys will be reimbursed on production of a valid ticket.

Non-Discriminatory Practice: The YJS is committed to providing an equal service to everyone and is opposed to discrimination on the grounds of gender, race, age, ability, ethnicity, religion, sexuality, disability or for any other reason.

Your Records & Confidentiality: Under the Freedom of Information Act 2000 you are entitled to view your records on request. Under the Data Protection Act 1998 your personal information is treated as confidential. However under this act we have a duty to share information about you if we have reason to believe you are at risk of harm, or present a risk of harm to others.

Complaints Procedure: In the event you have reason to complain about our service you can call into the office and ask to speak with the Duty Manager or ring 4272850 and request a complaints form

THIS FORM IS AVAILABLE IN OTHER LANGUAGES ON REQUEST