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THE CAMBRIDGE ACORN PROJECT
REFFERAL FORM – Therapeutic Work
This initial referral is for consultation with a practitioner from the Cambridge Acorn Project to discuss which, if any service, the family would like. Our service works a little differently as we aim to be family-led and for families to design their own package of intervention, based on their needs. We offer a ‘menu’ of different therapeutic interventions and the family, or young person, can choose what best suits their needs. This is a fully voluntary service. Please refer to attached information on the different kinds of interventions we offer:
The family would potentially like to access (please circle all that apply. We can discuss this further at our initial meeting):
1:1 TRAUMA-FOCUSED THERAPEUTIC SERVICE (CHILD)
1:1 TRAUMA-FOCUSED THERAPEUTIC SERVICE (ADULT)
EMPATHY BASED 1:1 THERAPEUTIC INTERVENTION (CHILD)
EMPATHY BASED 1:1 THERAPEUTIC INTERVENTION (ADULT)
ATTACHMENT FOCUSED PARENT/CARER AND CHILD JOINT WORK
SOCIAL PRESCRIBING (ADULT AND CHILD)
ADVOCACY (ADULT)
SOCIAL JUSTICE, ‘GREEN SHOOTS’, WORK (ADULT)
Have the family consented to this referral: YES NO
Has the young person consent to this referral: YES NO
1. BASIC DETAILS:
If the family have a CAF, or and F-CAF, this can be sent instead, with the family’s permission, as long as the above questions are answered and this referral form is signed by a parent.
Family name______
Child’s name______
Address:______
______
______
______
Telephone number: ______
Who is living in the household
NAME: / RELATIONSHIP: / DOB: / ETHNICITY:FAMILY TREE/GENOGRAM: On this page, if possible, please complete a genogram with the whole family as an exercise they can do together with you. If not, the practitioner will offer to do this with the whole family.
2: REFERRAL:
Why is this referral being made:Is the child experiencing any difficulties or distress?
Is the family experiencing any difficulties/distress?
What are the family’s views on their current needs, including their strengths?
Please give details of any significant events or traumas in the family. We do realise that this information can be very distressing for families however and they may prefer to talk to us about this face-to-face.
Are there any safeguarding concerns? Please give details.
Is there anything else we should know (any risks, for example)
3: REFERRER’S DETAILS:
Name:______
Agency:______
Address:______
______
______
Telephone number: ______
Email address:______
4: OTHER INVOLVED PROFESSIONALS (Family consent for us to contact)
Name: / Agency: / Contact details:5: CONSENT SIGNATURES:
I give consent for this referral to be made to the Cambridge Acorn Project to meet with a practitioner to discuss my family’s needs. I understand that the Cambridge Acorn Project will process my data in conformity with the Data Protection Act 1998. I understand that I will be informed about how to make a complaint, and how my data will be stored, when I first meet with a practitioner from the Cambridge Acorn Project.
Parent/carer:______Date: ______
Parent/carer:______Date:______
Referrer:______
Date:______
6: DRAWING – if the child or the parent/carer would like to, they can do a drawing below about their family, or something important to them – this is the family’s referral and this might help the referral feel more personal to them.