Welcome to Young Roots!

We are happy you will be joining our activities 

This form is to help keep you safe and so we can know more about you and stay in touch

YOUNG PERSON BASIC INFORMATION
First Name / Last Name
Phone Number / ______/ Email Address
Address / Postcode
Date of Birth / Current Age
Country / When did you arrive in the UK
Languages / Who do you live with?
EMERGENCY CONTACTS
Parent / Guardian / Carer
Name / Number / Email
Social worker name
Name / Number / Email
HEALTH
Do you have any medical issues?
(e.g. allergies, asthma, epilepsy – give details) / Yes No
Details: …………………………………………………………………
…………………………………………………………………………
Do you have any dietary requirements (e.g. halal, no pork, etc. – give details)
YOUNG PERSON DETAILS
Sex / Male Female
Ethnicity / White
English / Scottish / Welsh / Northern Irish / UK
Irish
Gipsy or Irish Traveller
Any other White background
Mixed Ethnic Background
Other ethnic group
Arab
Any other ethnic group
…………………………………… / Asian / Asian UK
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black / African / Caribbean / Black UK
African
Caribbean
Any other Black / African / Caribbean
Are you disabled? / Yes No Details:………………………………………………………..
What is your religion or belief / No religion
Christian
Buddhist
Hindu
Jewish
Muslim
Sikh
Other / Sexual Orientation / Heterosexual
Gay
Lesbian
Bisexual
Other
Immigration Status / Refugee
Asylum Seeker
EU Migrant
Non-EU Migrant (on a visa)
British
Undocumented
Don’t know
Other / Are you in the UK alone or with your family? / I am here alone
I am with family

Please tick this box and sign below

I consent to Young Roots keeping this information on our database.

Young person’s signature:
Date:
Parent/carer/social worker’s signature:
Date:

YOUNG ROOTS REFERRAL FORM (EXTERNAL)

Young Roots takes referrals of 11 – 25 year oldrefugees, asylum seekers and undocumented migrants.

Referrers details

Date /
Address
Name
Organisation
Email Address
Contact Tel. No

Young persons details

Name
First Language / Interpreter needed?
(Please tick) / Not at all
For complicated issues
Always
Looked After? / Responsible Local Authority
Housing type / Foster carer
Hostel or semi independent unit
Hotel/ B&B
Street homeless
Destitute, with friends
Living with a relative
Living with parents
NASS Accommodation
Other:
………………………………………... / Is the young person age disputed? / Yes
No
Don’t know
Have there ever been any concerns about the young person’s mental health?
Has the young person ever exhibited offending behaviour? (Please give details of the offence/s)
Is there anything else it would be useful for us to know about this young person?
Which service(s) are you referring to?
(Select all that apply) / Youth groups and holiday activities(North London)
Youth groups and holiday activities (Croydon)
Peer support project (College of North West London)
Peer support project (Croydon)
Casework (North London)
Casework (Croydon)
If referring a young person to our casework service please explain the reasons for this referral, i.e. what support does the young person require?

Thank you for completing this form.

For North London referrals, please send completed form to

For Croydon referrals, please send completed form to