REFERRAL FORM

The Referring Authority / Name of Placing Authority
Details of all LA’s bearing responsibility for the child (e.g. supervising authority) / Social Worker/Team Manager address:
Guardian Ad Litem: / Social Worker/Team Manager address:
Tel:
Fax:
Young Persons Details / Full Name:
Preferred Name: / Cultural Identity/Nationality: / DOB / Age / Gender
Details of Religious belief:
Details of Child Protection Issues/on register etc: / Legal Status (Children Act 1989)
Accommodation
Interim Care Order/Full Care Order
Remanded to L.A.
Others, give details
Other relevant orders (e.g. Adoption): / Record of offences/cautions/outstanding criminal matters:
Birth Mother: / Full Names:
Date of birth: / Address:
Tel No:
Cultural Identity/Nationality:
Birth Father / Full Names:
Date of birth: / Address:
Tel No:
Cultural Identity/Nationality:
Does the father have any parental responsibility?
If so give details:
Other significant adults: / Full Names:
Date of birth: / Address:
Tel No:
Cultural Identity/Nationality:
Parental responsibility?
Other significant adults/carers: / Full Names:
Date of birth: / Address:
Tel No:
Relationship to person:
Parental responsibility:
Siblings / Include full, half and step siblings. Continue on a separate sheet if necessary:
Name:
Date of Birth:
Relationship:
Address: / Name:
Date of Birth:
Relationship:
Address: / Name:
Date of Birth:
Relationship:
Address:
Placement History / Details of all placement history as a “looked after” young person: continue on a separate sheet if necessary.
Dates: / Name/address: / Type of placement: / Reason for leaving:
Education / Details of educational provision/schools attended.
Dates: / Name of establishment, address, contract name: / Type of placement: / Reason for leaving:
Please give details of any Individual Education Plan, Statutory Assessment or Statement of Special Educational Needs:
If the Young Person is over 16, please detail any educational qualifications.
Contact Arrangements / Significant people with whom the Young Person should/should not maintain contact:
Name: / Address and Tel No: / Relationship: / Contact Details:
Care Plan / Outline the long-term plan for the Young Person and how a placement at Blue Mountain Homes Ltd is consistent with Care Plan.
Placement Plan / Include the reasons for referral to Blue Mountain Homes Ltd and your expectations of what this placement is seeking to achieve
Young Persons views/wishes / Please note that the young people need to be aware of the placement aims and objectives/care plan
Details of the child’s awareness of Blue Mountain Homes Ltd. What information has he/she been given?
Does the child agree with the placement plan?
Parents/carers wishes / At Blue Mountain Homes Ltd, we encourage parental involvement/visits
Parent’s/carers views about the placement plan
LAC forms
The following information is required:
  • LAC Essential Information Record Part 1
  • LAC Essential Information Record Part 2
  • LAC Care Plan
  • LAC Placement Plan Part 1
  • Placement Agreement
  • LAC Placement Plan Part 2 – day to day arrangements

Health and Medication / Young Persons NHS number:
GP:
Name
Address:
Tel No: / Dentist:
Name:
Address:
Tel No: / Overall health and well-being (details of any disability/mental health issues)
Any ongoing health conditions or problems? (e.g. Diabetes, asthma, misusing substances, smoking)
Any significant accidents/injuries/illnesses? Further treatment anticipated?
Any specific dietary requirements or restrictions? Any known allergies?
Any aids and appliances (e.g. spectacles, hearing aids)
Other needs/wants/desires / Any special hobbies or leisure interests. Any needs arising from ethnic/racial origin, culture, religion, disability etc.
Risk Assessment / In order to assess presenting issues or risk and offer appropriate interventions, a full risk assessment will be carried out.
Has the young person previously been missing from home or care? / Outcomes of previous absconding / Potential risk to him/herself or others
Any significant factors or vulnerabilities? / Is there specific action you wish us to take
Risk assessment continued…
Incidents of physical violence / Incidents of deliberate self harm:
Suicide attempts: / Has the young person alleged abuse, displayed sexualized behavior:
Risk of fire setting: / Drug/Alcohol abuse:
Psychological Assessment:
Has the young person received a psychological/psychiatric assessment, if yes please give details:

On acceptance of placement, Blue Mountain Homes Ltd will confirm the placement date and return this page duly signed by an authorized signatory. The information in pages 1-5 of the Referral Form is part of this contact. A senior person within the placing authority and the child’s Social Worker must sign these terms and conditions.

Terms and Conditions

These terms and conditions are for the purchase and provision of care services for the named child. They are additional to any pre-placement agreement between and the placing authority

Young Persons name: / Date of Birth: / Invoicing address:
Social Worker: / Placing Authority:
Young Persons ref no: / Social Services Finance Officer:
Proposed date of Placement: / Proposed length of placement (if known):
  • FEES: £3200-£4,500 (on assessment of need) per week payable before the end of each 28-day period commencing with the date of placement.
  • CARE SERVICES: Blue Mountain Homes Ltd undertake to provide the services outlined in the brochure and to ensure that standards are maintained at all times
  • ADDITIONAL SERVICES: Where additional services are required these may be agreed in writing with the placing authority an additional charge may be made
  • ALLOWANCES: The fees include pocket money, bonus payments, telephone allowances and Christmas/Birthday allowances. Placing authorities are expected to make reasonable provision for Christmas/Birthday etc.
  • CLOTHING: A weekly clothing/toilet allowance is included in the fee. However, all children are expected to have an adequate supply of clothing, footwear and toiletries with them at the time of placement. If they do not, Blue Mountain Homes Ltd will purchase the missing items and bill the placing authority.
  • MEDICALS/HEALTH NEEDS: Medicals are the responsibility of the placing authority. Blue Mountain Homes Ltd will arrange medicals where required, but will bill the placing authority. Health requisites e.g. cost of spectacles will be billed to the placing authority.
  • LEGAL COSTS: The placing authority is responsible fore the cost of any legal representation/ court appearances for the child. (Blue Mountain Homes Ltd will assist in application for legal aid)
  • PERSONAL POSSESSIONS/CRIMINAL DAMAGE: Blue Mountain Homes Ltd does not accept responsibility for personal possessions lost, stolen or damaged during placement, save where this is due to the negligence/breach of duty of Blue Mountain Homes Ltd staff. Blue Mountain Homes reserves the right to bill the placing authority foe theft/damage by the child, particularly where this affects another child in placement.
  • BLUE MOUNTAIN HOMES reserve the right to seek redress from the placing authority for a young person’s deliberate, willful and gross negligence in relation to theft, fire and serious and persistent criminal damage, which could adversely affect other children and young people in placement.

This will include any attempts or actual arson.

  1. RESERVED PLACES: When the child is absent, for whatever reason, full fees remain payable.
  2. NOTICE PERIOD: Either party may terminate the placement on not less than seven days notice. There may be times in the event of serious incidents or child protection issues where the Managers/Child Care Director reserves the right to insist that the placement ends before seven days. The minimum 28-day charge remains payable irrespective of why the placement is terminated
  3. INFORMATION: It is the responsibility of the placing authority to ensure that all relevant information is communicated to Blue Mountain Homes Ltd in a timely fashion. Where material information has been withheld/not communicated, Blue Mountain Homes Ltd may, at their absolute discretion, terminate the placement, or this contract, forthwith.
  4. VARIATIONS TO CONTRACT: Any variations to these terms and conditions must be in writing and signed by both parties
  5. QUALITY ASSURANCE: It is the policy of Blue Mountain Homes Ltd to continuously review and improve all aspects of service provision. Should you have ant concerns in relation to the placement, please contact the Manager or Directors and your concerns will be investigated and responded to.

Signatures to Contract
Signed by duly authorized senior person on behalf of the placing authority:
Name:
Position:
Date: / Signed by Social Worker:
Name:
Date:
Signed on behalf of Blue Mountain Homes Ltd:
Name:
Position:
Date:
CONFIRMED PLACEMENT DATE:
CONFIRMED LENGTH OF PLACEMENT (IF KNOWN):

Please also supply a copy of the child’s birth certificate, a copy of the most recent medical report and copies of school reports, education statements etc.

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