Families First

Functional Family Therapy Referral Form

2017

Confidential and without Prejudice

Note: Please read the enclosed guidelines for making a referral for Functional Family Therapy. Please ensure all relevant sections are completed.

Date when completing form: ______

Section One

Details of youth

Name of young person:
Current Address:
Phone Number: Mobile Number:
Email address :
Date of Birth: Age:
Nationality/ Ethnic back ground:
Has this young person been in receipt of Families First Services in the Past : Yes/No
If yes please provide details and approximate dates:

Background Information

Name of Parent/ Guardian:
Address:
Phone Number: Mobile Number:
Email address:
Marital status : Nationality:
If one parent is not living in the family home, does the young person have contact/ relationship with him or her? Yes/No
If yes please provide contact details:
Address:
Phone: Mobile
Email:
Name and ages of siblings:
Is anyone one else residing in the home? Yes/No
If yes can you please expand on the relationship between that person and the referred young person?

Referrer Details:

Name of Person Referring and Job title :
Address of Organisation:
Phone number & Times of availability:
Email address:
Relationship with the Family:
Have you informed the Adolescent/ family of this referral? Yes/No
Please provide details of response including any concerns the family may have in relation to this referral :

Section Two

Reasons for referral: (Presenting problem, please be specific)

______

Section Three

Is there any other significant information, which you as a professional feel should be included on this form (e.g. problems at home or at school, behavioral management and emotional trauma such as bereavement?) Please describe:

Is this adolescent known to TUSLA Child and Family Services?: Yes/NO

______

If case is currently open, state name of social worker and contact details:

______

Is this adolescent currently on the Child Protection Register? : Yes/No

______

Is this adolescent currently attending Child Adolescent Mental Health Services? Yes/No

If yes please provide details?

______

Is this adolescent currently prescribed medication to help with psychological issues? Yes / No

If yes please provide name and type of medication.

______

Are there any clinical diagnoses or addiction issues within the family? ______

______

______

Are there any known or established risks to Staff safety and wellbeing that you would like Families First to be aware of, especially bearing in mind that the majority of Family therapy sessions take place in the Family’s Home.
A therapist usually works alone and the service is sometimes delivered out of hours.

______

Please complete the Risk Factor Table below:

None / Mild / Moderate / Severe
Suicide
Self Harm
Harm to other
Legal/Forensic

Is the young person currently in receipt of services from any other agency, and if so, what is the focus of that service?

______

______

What specific support are you/agency currently providing and will your service be maintaining involvement with this family while Functional family therapy is being delivered?

****Please include any relevant reports and/or evaluations completed that pertain to the referred young person.

Please forward all referrals to

Alice Ann Lee

Families First,

Unit 3 Oakfield Industrial Estate,

Clondalkin,

Dublin 22.

Telephone: 01 4574752

Email:

Clondalkin Behavioural Initiative Ltd. trading as Archways.

Company registered in Ireland No. 430172

Registered Charity Number 17603 Families First

Unit 3 Oakfield Industrial Est.

Clondalkin, Dublin 22

Email:

Tel: 4574752