PALZ+ REFERRAL FORM
PALZ+ focuses on engaging young people 8-13 year olds, through early intervention and working in partnership with schools, parents, local agencies and the community for young people to:
·  Behave in a socially accepted fashion at home, school and in their communities.
·  Become resilient and self-confident with improved social skills and emotional wellbeing.
·  Be supported to become resilient with improved knowledge and safety and therefore reducing risk
Please complete as fully as possible in capitals and put a tick or cross in all boxes. If the referrals form is incomplete it may be returned for further information or may not meet our threshold to be worked with.
The more information you can provide the better it will enable us to work with the young person.

YOUNG PERSON’S PERSONAL DETAILS

Surname / Forename
DOB / Gender / Male / Female / Tel
Address / Postcode
School / Contact

YOUNG PERSON’S PRINCIPAL CARERS

Surname / Forename / Relationship to child/young person / Parental responsibility
Yes / No
Yes / No

OTHER HOUSEHOLD MEMBERS (INCLUDING NON-FAMILY MEMBERS)

Surname / Forename / DOB / Relationship to child
REFERRAL DETAILS
Referred by / Agency or relationship to child/ young person
Address
Postcode / Tel
Date Referred
CHILD/YOUNG PERSON’S ETHNICITY
Asian or
Asian British / Bangladeshi / Indian / Pakistani / Any other Asian background
please specify:
Black or
Black British / African / Caribbean / Any other Black background
please specify:
White / British / Irish / Any other white background
please specify:
Mixed / White & Black
African / White & Black
Caribbean / White & Asian / Any other Mixed background
please specify:
Chinese or other ethnic group / Chinese / Any other ethnic group
Please specify:
Child/young person’s religion
Spoken language(s) of child / Spoken language(s) of parent(s)
Is an interpreter or signer required? Yes No
Any other communication needs? Please specify
KEY AGENCIES
(PLEASE TICK BOX IF CURRENTLY WORKING WITH THE FAMILY)
GP / Name / Health Visitor / Name
Tel / Tel
Voluntary Organisations / Name / Education Social Worker / Name
Tel / Tel
School / Name / Police / Name
Tel / Tel
Youth Offending Team / Name / Dentist / Name
Tel / Tel
Community Mental Health / CAHMS / Name / Social Services / Family Centre / Name
Tel / Tel
School Nurse / Name / Other / Name
Tel / Tel
GUARDIAN’S CONSENT
TO PALZ+ REFERRAL AND PARTICIPATION IN ALL PALZ+ ACTIVITIES
TO PALZ+ CONTACTING KEY AGENCIES WHEN REQUIRED
PARTNER AGENCIES WILL BE GUIDED BY THE INFORMATION SHARING PROTOCOL AND DATA PROTECTION ACT
Signature / Date
REASONS FOR REFERRAL
§  Issues around school attendance and behaviour Yes No
School exclusion? Current Yes No Previous Yes No
Percentage attendance at time of referral? / ______%
§  Behaviour Concerns being expressed regarding the child/young person
Within the home School Community
§  Parenting
Parents expressing concerns regarding managing their child/young person’s behaviour, i.e. routines/disciplines
§  Relationship difficulties
Children/young people experiencing relationship difficulties within the:
Family School Peers Community
§  Criminality Are any of the following in the young person’s life offenders:
Parents Family member Sibling Themselves
§  Poor housing home is not suitable to the needs of the young person
§  Low income Children/young person receiving free school meals
§  Emotional and mental health concerns
Self harming Yes No Poor self-esteem Yes No
Low mood Yes No Anxieties or phobias Yes No
Bereavement Yes No
§  Is the young person struggling with their identity Yes No
§  Safety concerns
CSE Yes No Online safety Yes No
Road/water safety Yes No Prevent Yes No
§  Are there concerns around weight management Yes No
Needs exercise sessions Yes No Needs support around diet Yes No
CHILD PROTECTION REGISTER
Is the child subject to a Child Protection plan: Yes No
If Yes please give details______
Any other social care involvement Yes No Details -______
What are you or others worried about?
What has happened that has made you worried about this child? – Actual previous history, emotional and physical and impact?
What are you worried could happen if support is not available?
What is making it harder to deal with the concerns? Barriers/obstacles, etc?
What’s working well?
Existing safety. When the danger was present, who supports or what has been done to support. Own resilience?
Existing Strengths. What are people doing to address the issue? Who is trying to help?
What needs to happen?
What would help to move the young person forward?
Do you feel the young person needs group work, one to one work or both?
One to one Group Work Both

How would you score where the young person is on the scale?

0  10

0 is the worst things can possibly be and 10 is the best.

V2 August 2016