Children & Young People Team
CHCP West Lothian Council including Mental Health/Mental Wellbeing
. REQUEST FOR SERVICE .
If you have concerns regarding the child’s immediate mental health please access urgent medical attention.
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Name:
Address:
Parent(s) / Carer(s) Name:
Tel No (Home):
Tel No (Mobile):
Date of Birth: . . Age: . .
Gender: Male/Female Delete as applicable
School:
Class: . Attendance% . (If an issue)
Name & address of GP:
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Awareness of Referral Delete as applicable
Are the parent(s)/carer(s) aware of this referral? Yes / No
Is the young person aware of this referral? Yes / No
Is the GP aware of this referral? Yes / No
Legal Status Delete as applicable
Looked After/Accommodated: Yes / No
If Yes Which Category: . .
Child Protection Register: Yes / No
Referrer Details:
Name:
Designation:
Referrer Contact Address:
Contact Tel No:
E-Mail Address:
Signature: Date:
Completed referrals should be returned to faxed to 01506 282949 or posted to
Children and Young People Team, Bathgate Partnership Centre, South Bridge Street, Bathgate, West Lothian EH48 1TS
If you require any further information please telephone 01506 282948
IT IS ESSENTIAL THAT YOU NOTIFY THE WORKER IF THERE ARE ANY HEALTH & SAFETY ISSUES
This form has been designed to be completed on-line. The boxes can be increased to accommodate the volume of information you have.
Areas of Concern (Please tick all that apply and provide details):
Behaviour Attendance Issues Health Issues
Family Issues Community Issues Transition Issues
Mental Health & Wellbeing Peer Relationship Issues Other Issues
Please state your concerns:
______
Any recent changes affecting the young person (including social background):
______
History of Support and Interventions:
Group Work 1 : 1 Work Additional Support Needs
Timetable Modification Referral to AAG Previous Exclusions
Referral to Psychological Services Referral to Reporter Other (please specify)
Details:
______Contact with other agencies – e.g. Police, Social Work, Youth Action Project:
______
Aim of referral and expected outcomes:
______
Group Work: Delete as applicable
Would the Parent benefit from a Parenting Group Yes / No
Would the child benefit from a Group Yes / No
______
Additional Information:
______
Completed referrals should be returned to faxed to 01506 282949 or posted to
Children and Young People Team, Bathgate Partnership Centre, South Bridge Street, Bathgate, West Lothian EH48 1TS
If you require any further information please telephone 01506 282948
Children & Young People Team
CHCP West Lothian Council including Mental Health/Mental Wellbeing
REQUEST FOR SERVICE
Notes for Completion
This form has been designed to allow referrals to all branches of the Children and Young People Team via one form. The team offers support to all eleven high schools and their feeder primaries in West Lothian.
In order for us to provide the best service we can to young people and their families, it is vital that we have as much information as possible from you, the referrer. While we understand that it can be difficult to provide all the information we require in the referral form, all information has been deemed necessary for us to make an informed decision on the suitability and appropriateness of our service.
Failure to provide sufficient information may result in a delay to the request being processed.
Please refer to these notes to guide you through the completion of the form but please feel free to contact any member of our team if you require further information, Telephone 01506 282948.
Young Person’s Details
Please complete this section fully. It is very important to have the correct name, address and DOB for the young person, for health and safety reasons, and for home visits to be undertaken.
It is also helpful for us to know who else is living in the household, especially but not exclusively siblings.
Awareness of Referral
In order to engage with a young person and/or their family we must have parental/carer permission. While Family Support Workers do not need permission to visit a home, the family should have been informed via the non-attendance procedure that a Worker visit may be required.
Please can you complete the Awareness of Referral section fully (including any reasons why others are not informed).
Referrer Details
Please sign here and provide us with your telephone number and email address, etc. This verifies all the information on the form and gives us your up to date contact details and date the referral was made. Good practice is to ensure that all relevant staff (within your service) who work with the young person, are aware of this referral.
Areas of Concern
Please tick all the areas of concern for this young person, in order to inform our service as fully as possible. There is also space for you to provide further details if required.
Any recent changes affecting the young person (including social background)
Please use this space to give us any information you can about the young person’s background and current social situation. This will help us to make an assessment of the young person and/or their families and their needs. In the case of Worker visits, any information about the home situation is very helpful.
History of Support and interventions
This section allows you the opportunity to tell us which support has been offered previously.
Contact with other agencies
Please use this box to let us know if other agencies are involved with the young person and their family. This will insure that there is no duplication of services.
We may contact these agencies for additional information and to work in partnership with them.
Expected outcomes and aim of referral
Please let us know what the desired outcomes for the young person are from your perspective. What changes would you like to see in the young person’s situation or behaviour.
This will contribute to the allocation of the most appropriate service.
Groupwork
Please indicate whether you think the young person or parent would benefit from groupwork.
Additional Information
Please use this space for any other relevant information.
IT IS ESSENTIAL THAT YOU NOTIFY THE WORKER IF THERE ARE ANY HEALTH AND SAFETY ISSUES.
Please take note of the above statement. While it is often unwise to note on the form any issues that may have to be taken into account by staff considering or planning a home visit, it is vital that our staff are informed of any health and safety issues that have already come to your attention.
Please ensure that you take the time to let us know of anything that could impact upon our staff undertaking home visits.
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