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 / Religion

Address:______

(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 / Religion

Parent’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 involvement

BACKGROUND 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: