College Street Centre, College Lane

d’n’a Services for Young People SERVICE REQUEST FORM

College Street Centre, College Lane

Newcastle upon Tyne, NE1 8DX

Tel (0191) 277 7377 Referral Date:

Referrer Details Or Self Referral

(If you are a young person or parent & need help to complete the form call DnA)

Name: Agency/establishment:

Contact details (telephone & email address):

YOUNG PERSON DETAILS:

Name: Date of Birth: Age at 1st Referral:

Address: Gender: Ethnicity

Telephone:

Home:

Postcode: Mobile:

How would the young person prefer us to make contact with them?

Legal status: Looked After s.20 CA 1989

Looked After s.31 CA 1989

At: School College Training Course Employment Other

DETAILS:

Please confirm that concerns discussed with young person and they are aware of referral? (if left blank referral will not be accepted)

Parent/Carer Details:

Name(s): Capacity/ Relationship:

Telephone

Address: Are they aware of this referral? YES NO

Who has Parental responsibility if different from above?

(name of individual or Local authority )

G.P. DETAILS:

Name: Address:

Telephone:

Agencies/Professionals involved with young person/family:

1. Worker Name:
Agency:
Contact details:
(Phone and/or email)
3. Worker Name:
Agency:
Contact details
(Phone and/or email)
/ 2. Worker Name:
Agency:
Contact details:
(Phone and/or email)
4. Worker Name
Agency:
Contact details
(phone and/or email)

SUBSTANCE USE:

What substance(s) are used? Frequency? How Much? How Taken?

(Identify all and ask yp to prioritise) (Days per week) (quantity/cost) (smoke, inhale, snort, inject)

ADDITIONAL RISK FACTORS

History of parental or sibling substance misuse ¨

Under 18 and living independently ¨

(this includes living with friends and hostel accommodation)

Aged 14 or younger ¨

History of going missing from home ¨

(this includes residential units, foster placements etc)

Engaged in offending to fund substance misuse ¨

OTHER RELEVANT INFORMATION: (Consider both protective and risk factors. Describe what you know of the young person’s substance use and how it impacts on them and others. Has a CAF been completed, if not why not?)

Submit your referral via email to:

For Admin Purposes:

Manager’s Signature: Date

Information entered onto database ¨ Date:

Admin Signature Date:

Progress to Assessment ¨

Allocated Worker: Date Referrer informed ¨

Referral not appropriate ¨

Reason

Referrer informed ¨

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