Referral Form

To help us with our assessment please emphasise aspect of behaviour and needs as at present.
Any positives or ideas of ‘ways in’ to the young person would also be appreciated.

Please complete all fields as necessary and submit when complete.

OUR CARE TEAM WILL BASE ITS DECISION ON THE INFORMATION YOU SEND US





Your details

Your Name (required)

Your email address (required)

Please retype your email address (required)

Your organisation (required)

Your telephone number (required)


Candidates details

Full name of young person(required)

Legal status (required)

Date of Birth - dd/mm/yyyy(required)

Current Address (required)

Telephone number of current address (required)

email of current address (required)

Date of referral - dd/mm/yyyy(required)


Justice

Court appearance pending?

Nature of alleged offences


Medical requirements

Drug and substance misuse

Verbal abuse of others

Physical abuse of others

Self harm


Education

Statement and type

Reading age

Date last in school - dd/mm/yyyy

Temperament

Previous reaction to support offered

Specific concerns and present behaviour

Potential triggers for behaviour

Has a risk assessment been done? (response required)

If YES please supply a copy


Risk Profile

Risk rating key : 1 = Low Risk, 2 = Significant Risk,
3 = Serious Apparent Risk, 4 = Serious and Imminent Risk


Ideas of self injurious behaviour -
Risk rating -


Ideas of harm towards others -

Risk rating -


Impulsivity / lack of control -

Risk rating -


Physical harm to others -

Risk rating -


Threats / Intimidation -

Risk rating -


Suicide Attempts -

Risk rating -


Domestic Risk (Fire risk, appliances etc) -

Risk rating -


Drug / Alcohol / Solvent Abuse -

Risk rating -


Criminal Behaviour (damage to property, possible assault) -

Risk rating -


Sexual risk to staff / others - YES NO

Risk rating -


Road Safety -

Risk rating -


Abuse / Victimisation by others -

Risk rating -


Mental Health Problems -

Risk rating -


History of allegations against staff -

Risk rating -


Risk to staff -

Risk rating -


Risk to local community -

Risk rating -


Damage to property -

Risk rating -


Absconding -

Risk rating -


Additional details (if necessary) -

How many incidents involving the necessity for immediate (within 12 hours) management attendance has this young person been involved in in the past three months? -

Name of person completing this form (required)

Date

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Head Office

(Office hours 9am – 5pm Monday to Friday)
17 Anchor Street
Southport
Merseyside
PR9 0UT UK
Tel : 01704 518915


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