42Nd Street Referral Form Young People, Parents & Carers (Referring 13+ Year Olds)

Office use only:

Date referral form processed following incomplete referral
Pending closure date following no contact from YP
Client ID

42nd Street Referral Form – Young People, Parents & Carers (referring 13+ year olds)

If you need help to complete this form please contact us on 0161 228 7321

Yes / No

Please confirm that the young person consented to this referral:

Yes / No

I am referring myself to 42nd Street

Yes / No

I am a parent or carer referring a young person

Unknown / Yes / No

This is the first time I have been / the young person

has been referred to 42nd Street

Date of Referral

YOUNG PERSON’S INFORMATION:

Title / First Name / Surname
Age / Date of Birth

Gender:

Male / Trans Male / Gender Queer / Non- Binary
Female / Trans Female / Other gender identity Please state:

I live in:

Manchester / Tameside & Glossop / Trafford / Salford

Contact Details:

Address line 1
Address line 2
Town
Post code
Telephone (1)
Mobile
Email

How We Can Get In Touch With You? (Young Person)

GP Details:

Name of GP
Name of GP Surgery
Address
Post code
Phone Number
Email
Not registered with a GP (Please tick)

42nd Street takes GP details for funding purposes. We would not ordinarily contact your GP without speaking to you first. However, if we are very concerned about your safety and well-being, we may need to contact them.

I am a Parent / Carer and am making this referral on behalf of a young person. My contact details are:

Contact Details:

Name:
Address line 1
Address line 2
Town
Post code
Telephone (1)
Mobile
Email

How We Can Get In Touch With You? (Parent/carer making a referral)

Ok to post mail to you? / Yes / No
Ok to phone you (1)? / Yes / No
Ok to phone mobile? / Yes / No
Ok to text you? / Yes / No
OK to leave a voicemail? / Yes / No
OK to email you? / Yes / No
Preferred way for us to contact you? Please state
How did you hear about 42nd Street?
42nd Street publicity / 42nd Street website / Family/Friend
GP / Social Media / Mental Health Professional
Other Professional (Please state):
Other (Please state):

REFERRAL INFORMATION

Can you tell us why you would like to come to 42nd Street for support?

It might be helpful to think about: What is going on? How is this affecting you? How long has this been affecting you? What would you like to be different?

Please give details:

What types of support or activities are you interested in at the moment?

Individual therapeutic support: includescounselling; one-to-one support; advocacy; and IAPT* services (Low and High Intensity Cognitive Behavioural Therapy (CBT); EMDR; Counselling for Depression).
*IAPT Services are only available to those with a Manchester GP.
Creative and group work programmeincludes arts, identity, therapeutic, issue based groups and social action projects.
Not sure

If you would like to know more about 42nd Street, our individual therapeutic support or creative and groupwork programme, you can find more information on our website or you can call us on 0161 228 7321.

Managing Difficult Feelings - Please tell us about your experiencesof the following:

If you tick yes to any of the questions below, 42nd Street may contact you for further details.

We need to make sure everybody is safe at 42nd Street. Please tell us if there is anything you think we need to know about you which might put others at risk. / No / Yes
Doyou self-harm? / No / Yes, sometimes / Yes, often*
Do you have suicidal thoughts? / No / Yes, sometimes / Yes, often*
Have youhad thoughts of suicide in the past 2-3 weeks that you have wanted to act upon? / No / Yes, sometimes*
Yes, often*
Have youpreviously attempted suicide? / No / Yes, once* / Yes, more than once*
If yes, when was this?
Please give details:
Would you like us to send you some resources whilst you are waiting to be contacted? / No / Yes

Are there any other issues about your mental health you would like us to know at this stage: e.g.: physical health difficulties; medication prescribed by a doctor/psychiatrist; other crisis or risk issues, a formal diagnosis from a GP or Psychiatrist.

Please give details:

Are you getting any other support from any other professionals or services?

e.g. social worker; psychiatrist; psychologist, etc.

Yes No

Please give details:

Please let us know of any particular needs we need to be aware of when we contact you or offer you an appointment.

Please give details:

Appointment Preferences:

*Please be aware that preferences are not always available*Last available appointment 6.00pm at our office base on Mon, Tues, Wed & Thurs; 4pm on Fridays.

Appointment time: / Day / Evening / Either
Preferred worker gender: / Male / Female / Either
Preferred Project Type: / ‘Inside Out’ (LGBTQ+) / Disabled Young People’s project

Please tick if youneed a community based appointment

MY IDENTITY

Ethnicity

White- British / Asian or Asian British- Pakistani
White- Irish / Asian or Asian British- Bangladeshi
Any other White background / Any other Asian background
Mixed-White and Black Caribbean / Black or Black British- Caribbean
Mixed-White and Black African / Black or Black British- African
Mixed-White and Asian / Any other Black background
Any other mixed background / Chinese
Asian or Asian British / Any other ethnic group
Asian or Asian British- Indian / Prefer not to say

Disability:

Not Disabled / Multiple disabilities
Physical disability / Unseen/invisible disability e.g. epilepsy, asthma etc.
Blind/partially sighted / Asperger’s/ autism
Deaf/hard of hearing / Other
Learning disability/difficulty / Prefer not to say

I am a carer for a parent/carer or family members:

Yes / No / Prefer not to say

WHAT HAPPENS NEXT?

We will contact you to arrange an initial assessment. This is an opportunity to talk more about the difficulties you are experiencing and how 42nd Street can support you. We will contact you by phone unless you tell us otherwise. So please make sure you give us a phone number and also indicate whether it is OK for us to leave a message for you on Voicemail. We will write to you to confirm the date and venue for your assessment.

Some young people find it helpful to write down some key things they would like to tell us when they come to the assessment. This can help you to feel less nervous. If you would like to come with a friend, professional or family member, they are welcome to stay in our waiting area.

If you have any worries or questions, please get in touch on 0161 228 7321.If you would like more information about how we keep your information safe or our confidentiality policy, please visit our website:

When you have completed this form please send it to us by post or fax:

42nd Street, The Space, 87 – 91 Great Ancoats Street, Manchester, M4 5AG/FAX: 0161 228 0528

OFFICE USE ONLY:

Outcome of Referral:

Admin: Referral entered onto database: / Admin Initials: / Date:
DUTY: Referral Screening
Outcome: / Not accepted / (Tick): / Disengagement Form complete and sent to Admin (Yes):
Admin: Disengaged on database (Tick):
DUTY: Referral Screening (Outcome):
* Where an asterisk is present, please consider use of the screening tool. / Accepted
(Tick relevant route) / IM / Geographical Text (No-reply) confirmation of referral acceptance/will contact to book IM (Tick)
Group only (no risk identified) / Group name:
DUTY ACTION
(Groups / risk identified only) / Accepted / Group only (risk identified – IM is required) / Duty Worker allocated IM to (Fieldworker Name):
Engagement Worker: Referral entered onto general waiting list / general groups or group specific waiting list as relevant (if no risk identified): / Initials: / Date:
Engagement Worker: Unable to speak to YP to offer an IM appt. / Following contact attempt to book IM / no response - text to yp (2 week reply window) (Tick) / No reply after 2 weeks, close case and letter sent to referrer saying no service required. (Tick)
Engagement Worker:
IM Booking / Date and time of IM: / IM worker name: / Appt letter sent to confirm (tick)