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CIS
Crisis Intervention Service

REFERRAL FORM

DATE / TIME / CASE NUMBER
Name of Social Worker:
Position:
Team Name:
Based at:
Telephone: / Mobile: / Fax:
E-mail:
Family Name / Telephone Number / Address and postcode
Referred Child Name / DOB / Age / School & Contact / Legal Status
Siblings(s)
Adult Name(s) / DOB / Age / Relationship to Child(ren)
ETHNICITY
FIRST LANGUAGE
ANY DISABILITY? / YES/NO / Details
Office Initiating Referral: / Approved by Manager
Allocated Social Worker:
Reason for Referral / Comments
Crisis Intervention Service (CIS)
Multi Systemic Therapy (MST)
External provider involvement
Inclusion Criteria: Young people must meet Criteria 1 and 2 or 3 below to be suitable for MST involvement
1.  Is the young person aged between 11-17 years? Y N
2.  Is the young person at imminent risk of coming into care or custody? Y N
3.  Does the young person exhibit anti-social behaviour in more than
one setting (i.e. at home, at school, in the community)? Y N
Exclusion Criteria : Any young person meeting any of the criteria below will NOT be suitable for a referral to MST
1.  Is the young person living independently? Y N
2.  Is the young person actively psychotic, homicidal or suicidal? Y N
3.  Are the concerns around the young person primarily around
Sexual offending in the absence of other antisocial behaviour? Y N
4.  Does the young person have a pervasive developmental
Disorder (for example, Autism or Asperger’s)? Y N
Inclusion criteria for External Provider Involvement
1.  CIS/MST’s workforce status is currently at Capacity Y N
2.  Young Person is at imminent risk of entering the “Care System” Y N
If External Provider Involvement identified:
This service will prevent the child going into: / Foster Care
Residential Care
Mother and Baby Unit
(please select just one)
Please advise the expected number of hours per week which are required for interventions from an external provider? / Number of hours per week:
Expected duration of the service (12 weeks is the maximum allowed normally) / Number of weeks:
Next anticipated date of review / Date of review:
RISK ASSESSMENT SUMMARY
Which of the following have affected or are continuing to affect the family you are referring, and what is the current level of risk?
If actions need to be taken to reduce or avoid the risk, please mark as ‘High.’
Issue / Y/N / Low (√) / Medium (√) / High (√) / Details:
Safeguarding Children
Domestic Abuse
Physical/Verbal Aggression - from child
Alcohol/Drug/Substance use
Offending Behaviour
CSE Risk/s
Cultural/Identity Issues
Religious Issues
Immigration/Asylum
Housing Issues
Medical Condition
Physical Impairment
Learning Difficulties
Parenting Skills
Absconding Behaviour
Risk of Violence to Staff
Risk of Self Harm/Suicide
Education issues
Sexually Harmful Behaviours
Other (please specify):
DETAILS OF SAFEGUARDING CONCERNS
Please include nature of concerns, details of any child subject to a Child Protection Plan, any ongoing investigations, etc.
Please indicate what service and outcomes you would like CIS, MST or External Provider to undertake and achieve?
1.
2.
3.
Print Name
Date

MST acceptance of Referral Request: YES NO CIS acceptance of Referral Request: YES NO

External provider acceptance of Referral: YES NO