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CGL Renew

Tower Hamlets Young People’s Substance Misuse Service

REFERRAL FORM- YOU CAN PHONE US WITH A REFERRAL OR COMPLETE THIS FORM AND EMAIL IT TO:

Date: …………………………………………..Referral taken by: ………………………………..

Is the Young Person at immediate risk if they do not receive a service?YES ☐NO ☐

PLEASE ENSURE ALL SECTIONS OF THIS FORM ARE COMPLETED

  1. REFERRERS DETAILS

Referrer’s Name: ………………………………………………………………….Position: ……………………………………………………………......

Agency Name & Dept.: ………………………………………………………….Name of School Lead (If Known): …………………………………………………………..

TYPE OF YOT REFERRAL - YRO☐YCC☐TRIAGE☐REFERRAL ORDER☐

Referrer’s Address......

Contact Telephone Number: ……………………………………………….Email: …………………………………………………………………......

School/ College Name and Address:......

Has the Young Person given consent to be seen at School/College? YES☐NO ☐

Reason for Referral: ………………………………………………………………………………………………………………………………………………………………………………

2. PERSONAL DETAILS

Forename: ……………………………Surname: …………………………..Date of Birth: ……………………… Age………..Male ☐ Female ☐

Young Person’s Residential Address: ……………………………………………………………………………………………………………………………………….

……………………………………………………….. Postcode: ……………………………………………. Telephone Number: ………………………………………

Has the Young Person given consent to be referred to Renew Young People’s Service? YES☐NO☐

Has the Young Person given consent to be contacted at the above address? YES☐NO☐

Has the Young Person given consent to be contacted on the above telephone number? YES ☐NO ☐

Has the Young Person given consent to contact his/her Parent/Carer? YES☐NO☐

Disability/Special Needs: ………………………………………………………..Language Needs: …………………………………………………………

Is the Young Person a Looked After Child? / YES☐NO☐
3. Accommodation
Living with Parent(s) / ☐ / Supported Housing/Hostel / ☐ / Children’s Home –LA / ☐
Family/Friends / ☐ / Living Independently / ☐ / YOI / ☐
Residential School / ☐ / Foster Care / ☐ / No Fixed Abode / ☐
Other (please specify): / ……………………………………………………………………..
The Young Person is in:
School / ☐ / College / ☐ / Unemployment / ☐
PRU / ☐ / Training / ☐
SEN / ☐ / Employment / ☐ / Other (please specify)

......

Is the Young Person Excluded from School? YES☐NO☐

4. ETHNICITY
White British / ☐ / White Irish / ☐ / White Other / ☐
White/Black Caribbean / ☐ / White Black African / ☐ / White/Asian / ☐
Bangladeshi / ☐ / Pakistani / ☐ / Indian / ☐
Black African / ☐ / Black Caribbean / ☐ / Black British / ☐
Mixed Other / ☐ / Asian Other / ☐ / Black Other / ☐
Chinese / ☐ / Vietnamese / ☐ / Somali / ☐
Other (please specify):
5. GP DETAILS

GP/Practice Name: …………………………………………………...... Address: ......

……………………………………………………….. Postcode: ……………………………………………. Telephone Number: ………………………………………

Has the Young Person given consent to contact his/her GP: YES☐NO☐

6. SUBSTANCE USE

PLEASE INDICATE MAIN DRUG OF CHOICE WITH AN *

Alcohol / ☐ / Amphetamine / ☐ / Benzodiazepines / ☐
Cannabis / ☐ / GHB / ☐ / LSD / ☐
Cocaine / ☐ / Magic Mushrooms / ☐ / Solvents / ☐
Heroin / ☐ / Methadone / ☐ / Poppers / ☐
Ecstasy / ☐ / Ketamine / ☐ / Tobacco / ☐
Crack Cocaine / ☐ / Steroids / ☐ / NSP / ☐

Other (please specify): ………………………………………………………..…If abstinent please state approximate time:……………………..

Is client injecting? YES ☐ NO ☐

7. ADDITIONAL INFORMATION

How would you describe the Young Person’s Mental Health?

......

Has a Common Assessment Framework (CAF) been completed for this Young Person?YES☐NO ☐

If yes, please attach a copy with this referral if possible

Has a risk assessment been completed for this Young Person?YES☐NO ☐

If yes, please attach a copy with this referral if possible

Please provide details of any risk issues and/or any other information that you think is relevant:

…………………………………………………………………………………………………………………………………………………………………………………………………………………

What would the YP like to achieve whilst working with Renew? ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………......

7. OTHER PROFESSIONALS

Is the Young Person involved with:

YOT ☐CAMHS/CSSS☐Social Services☐Any Other Agencies☐

Please provide details: …………………………………………………………………………………………………………………………………………………………………………..

Is the Young Person subject to a

Child Protection Plan☐Child In Need plan☐Looked After Child☐Other☐

Are there any other agencies involved with the Young person or their family?YES☐NO☐

If yes, please list the names of the agencies and contact below:

Name of Agency / Name of Keyworker/Lead Person / Contact Tel. No. & Email
8. METHOD OF CONTACT AND CONSENT

Does the YP give consent to this referral and to enter their information onto our Database?YES☐NO ☐

Would the Young Person like support for their parent/carer?YES☐NO ☐

If yes please make a referral to the Parent & Family Service

Where does the Young Person wish to be seen?………………………………………………………………………………………..

Young Person’s preferred method of contact:

Letter☐Text☐Telephone Call☐Telephone Call☐via referrer ☐

(Mobile)(Home)

THERE IS A REQUIREMENT FOR THE REFERRER TO BE AVAILABLE AND MAINTAIN CONTACT WITH RENEW YP SERVICE THROUGHOUT THE TREATMENT EPISODE AND MAY BE REQUIRED TO ATTEND AN UPDATE SESSION WITH THE CLIENT OR ASSIST IN MAKING CONTACT WITH THE CLIENT

PLEASE RETURN THE COMPLETED REFERRAL FORM TO:

CGL Renew Tower Hamlets Young People’s Service

Spotlight, 30 Hay Currie Street London E14 6GN

Email:or referrals can be taken over the phone on (0207) 536 8860/8869

THYP Service has an equal Opportunities and Confidentiality policies which it adheres to in all aspects of service delivery

ARegistered Charity No: 515691 and A Company Register by Guarantee No: 1842240