Young People Befriending Client Referral Form

Please be aware that this is a pilot offering 10 spaces on a first come first served basis in order to demonstrate the need and that there is a demand for this service. We are continuing to accept suitable referrals with the view to evidence that there is a continued need for the service in order to secure additional funding.

Please consult the Young People Befriending criteria (on the Dorset Mind website) before completing this referral form. Once complete, please post to: Dorset Mind, 3 Stratfield Saye, 20 – 22 Wellington Road, Bournemouth, BH8 8JN.

Please think about any information relevant to the befriending relationship. It is really important that we have sufficient information to match clients with asuitable Befriending volunteer. This information will also help Befrienders to understand what working with this client might involve. This includes any risk information that indicatespast risk or that a person is becoming more unwell or unstable.

Please be aware that without complete information the match may be significantly delayed or unable toproceed.

Client information:

Name: / Date of birth:
Age: / Gender: / Ethnicity:
Current address:
Postcode:
Email: / Phone/mobile:
Preferred method of contact: / Phone / Mobile / Email / Text

Parent/Carer/Guardian information:

Name(s): / Relationship (to client):
Current address:
(if different from client)
Postcode:
Email: / Phone/mobile:
Preferred method of contact: / Phone / Mobile / Email / Text
Has the client consented to this referral? / Y / N
Are Parents/Carers/Guardians aware of this referral? / Y / N
Client’s GP name and address:
Medical conditions: / (please provide details)
Is this young person in Care? (if yes, please  the appropriate and provide details below) / Y/N
Local Authority (Foster Care/Residential Care) / Area:
Private (Foster Care/Residential Care) / Area:
Looked After (Other) / Please State:
Leaving Care
How did you hear about Dorset Mind’s Young People Services? / (Please give specific details)

Please give us the following details about the young person:

School: / Tel:
Training: / Tel:
Employment: / Tel:
NEET: / Other:

Referrer’s details:

Name of professional: / Family Referred
Agency name:
Address:
Position of referrer:
Contact Tel No: / Mobile:
E-mail Address:

Please note any child protection/safeguarding issues and interventions:

Please  / (Please give details of professionals involved, dates, etc.)
Detail (If applicable)
CP
CAF
CIN
Other
1) / Please tell us a little about this young person and how they might benefit from Befriending?
(This might include aspects about their personality, likes, strengths, interests, whether they are quiet, shy, etc.)
2) / Please tell us about how this young person interacts with other people?
(This might include whether they are trusting, open, guarded, resistant or likely to become dependent slowly or quickly.)
3) / Please describe how much formal and informal support this young person receives
(Please provide more information about the nature and possible risks or needs associated.)
4) / Does this young person have any physical health issues, disabilities, sensory or mobility impairments that may be relevant for the befriending volunteer?
(This might include professionals involved (and frequency of support), family, friends, partner, etc.)
5) / Is this young person ata greater risk of harm from others? / Y/N
(If yes, please provide more information about the nature and possible risks associated.)
6) / Does this young person have a mental health diagnosis? / Y/N
(Please provide information including non-specified diagnoses)
7) / Does this young person have a history of any kind of abuse, trauma, or neglect?
Current: Y/N / Previous: Y/N
(If yes, please provide more information about the nature and possible risks associated)
8) / Does this person have a history of alcohol or substance misuse or dependency?
Current: Y/N / Previous: Y/N
(If yes, please provide more information about the nature, timescales and possible risks associated e.g. binge drinking or using psychoactive substances)
9) / Does this person have a current or previous history of self-harming behaviour?
Current: Y/N / Previous: Y/N
(If yes to any of the above please provide more information about the nature, timescales, plans, and methods considered/used.)
10) / Does this person have a current or previous history of suicidal thoughts/attempts?
Current: Y/N / Previous: Y/N
(If yes to any of the above please provide more information about & the nature, timescales, plans, and methods considered/used.)
11) / Could this person present a risk of harm to others?
Current: Y/N / Recent: Y/N / Historic: Y/N
(If yes, please provide more information about the nature and possible risks associated.)
12) / In your professional opinion is the young person currently suitable for lone working? (for more information, please refer to Dorset Mind’s Lone Working Policy on our website). / Y/N
13) / Is there any other information that might be relevant to the befriending relationship? / Y/N
(If yes please provide more info.)
Does this person have a risk assessment with your organisation? / Y/N
If yes, please attach and  that you have:
Referrer’s name: / Signature:
Date:

Young person declaration: (This referral must be signed by the young person. If it is not signed the form will be returned to you.)

I, ………...... confirm that I have given my consent for this information to be shared with Dorset Mind to support my application for the Young People Befriending Service.

Client signature:………...... ………...... Date:………......

Post referral to: Dorset Mind, 3 Stratfield Saye, 20 – 22 Wellington Road, Bournemouth, BH8 8JN