SAFE@LAST Referral Form

This form is to be used for referrals to the Specialist Runaways Services Team. Whilst it is important to complete the following as fully as possible, it is not imperative and should not delay or prevent referrals. However, sections marked * must be completed or the referral cannot be processed.

*Referred Persons Details:

Name: / D.o.b and age:
Home address: / Current address:
Disability: Yes/No if yes give details / Ethnicity:
Contact telephone number: / Spoken language:

Who cares for this young person?Parent/relative/L.A./Foster carer

*Potential risks or hazards in the home:

e.g. pets, smoking, DV.

*Family Details (other known household members or significant people – parents/carers, siblings etc):

Name / Age / Date of birth / Relationship to young person

Please continue on a separate sheet if necessary

Please tell us who else is or has been involved that you know of:

Name and role / Agency / Current or past / Contact details

*School details for each child living in the family home:

Name / Age/d.o.b. / Name of school / Contact in school

Please continue on a separate sheet if necessary

What if any SEN or health diagnosis in place e.g. ADD/ASD/ADHD/ODD?

If there is a Social Worker attached to this person/family, please give details:

Name and area/team / Status – CP/CIN/TAC / Contact details

How many times has the young person run away or been missing from home or care?

(South Yorkshire Police – missing from home officer will have this information)

*What type of support would be helpful?:

Type of support available: / Yes/No
Family support work
Young Person Support (Please indicate / below which support is required)
1:1 outreach work
Participation in Education and prevention programme in school (further details can be provided)

*Please give reason for referral:

In your opinion what previous work, to your knowledge, has been effective/ineffective in the past with this person/family?

What are the required outcomes from this referral?*:

Reduction in running away or going missing?
Better communication?
Improved health and wellbeing?
Stronger relationships?
Reduction in risk taking?

What risk taking behaviour is the young person displaying?

Drug use
Alcohol use
Sexual health
Self harming
ASB
Criminal behaviour
Aggressive behaviours
Attempting suicide
CSE
Other

Please add any other information you think may help us to be successful with this person/family:

*Form completed by:

Name of Agency:
Address:
Postcode: Telephone No:
E.mail:
Contact person:
Signature: Date:

*Consent for this referral is needed from the person/family being referred.

Family Support Referral Consent

Name of family:

Signature of consent:

Date:

Young Person Referral Consent

Name of young person:

Signature of consent:

Date:

Please e mail or mail this referral form, marked CONFIDENTIAL to SAFE@LAST, Specialist Runaway Services Team, 6 Clock Court, Campbell Way, Dinnington,S25 3QD.

Tel: 01909-566977 Email:

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