TRAFFORD TIME OUT PROJECT
REFERRAL FORM
NB * All information recorded on this referral will be shared with the family.
* Has the family consented to this referral being made? Yes/No
* Incomplete referrals will result in delays.
* PLEASE INDICATE IF THE REFERRAL IS FOR A YOUNG CARER OR A SIBLING OF A CHILD WITH COMPLEX AND ADDITIONAL NEEDS.
Date of referral:______
Family name(s):______
YOUNG PERSONS DETAILS
Name(s) / D.O.B / Gender / Ethnicity / ReligionAddress:______
(inc.post______
code)______
Phone no(s):______
Email:______
Any special needs:______
(including health, education, disability, language and communication)
First language:______
Is an interpreter required?______
YP immigration status:______
(if applicable)
FAMILY COMPOSITION
Single parent/2 Parents? Please indicate. Give details of absent parent (if known) below with other family members
Surname / Forename / D.O.B / Gender / Relation to Child / Parental Responsibility / Ethnicity / ReligionParent’s first language:______
Parents preferred method of contact:______
Any literacy support required? Yes _____ No _____
SUPPORT NETWORKSie. grandparents, other relatives, significant friends, etc.
Name: ______Name: ______
Address:______Address:______
______
Postcode: ______Postcode:______
Relationship to YP ______Relation to YP:______
REFERRER DETAILS (please include days/hours worked if part time/term time)
Name of Referrer:______
Agency Job Title:______
Address:______
(inc postcode)______
Telephone No:______
Mobile no:______
E mail address:______
KEY AGENCIES INVOLVED ( including school/college) and GP details
Name / Agency & Job title / Address inc postcode / Telephone number / Reason for involvementBACKGROUND INFORMATION/PRESENTING PROBLEM
(include: who is being cared for, diagnosis/prognosis of this person, is the condition relapsing/ remittent or chronic, the level and nature of care provided by the young person, the impact on the young person of their caring responsibilities or having a sibling with complex and additional needs. Any other relevant background information and affecting social factors.)
REASON FOR REFERRAL
What are you asking us to do?
Any identified risks? e.g substance/ alcohol misuse, smoking, unpredictable behaviour, history of violence, etc.
*Please attach copies of any previous/ current assessments with parent’s permission, including CAF, Initial assessments, core assessment.
CATEGORY OF NEED OF YOUNG PERSON (please tick)
Unknown Vulnerable Child in need
Child Protection Looked after None of these
Please return your completed forms to:
Action for Children
Trafford Time Out Project
21a Marsland Road
Sale Moor
Manchester M33 3HP
Or fax it to us on 0161 973 4915
If you require any further information or support to complete this form, please contact us on 0161 972 0090, or email
FOR OFFICE USE:
Date allocated:Name of worker: