CONFIDENTIALTO BE COMPLETED BY AGENCY

SEYMOUR HOUSE YOUNG PEOPLES SERVICE

REFERRAL FORM

YOUNG PERSONS DETAILS (FOR HH USE) CLIENT CODE:
NAME: DOB: AGE:
ETHNIC ORIGIN: GENDER:
ADDRESS:
POSTCODE:
TELEPHONE:
REASONS FOR REFFERAL (PLEASE GIVE AS MUCH BACKGROUND INFORMATION AS POSSIBLE INCLUDING WHO IS WORKING WITH THE YOUNG PERSON AND FAMILY)
OTHER AGENCIES INVOVLED WITH YOUNG PERSON (PLEASE TICK RELAVENT BOX/BOXES)
Social Worker Name:……………………………………………
Youth Offending Worker Name:…………………………………………….
Harbour worker Name:……………………………………………
CAMHS Name:……………………………………………
Any Other Agencies Name:……………………………………………
REFERRING SOURCE (AGENCY/NAME):
CONTACT DETAILS: / TEL NO:
FAX NO: / E-MAIL:
CASE WORKER/LINE MANAGER / CONTACT TIMES
SIGNATURE (REFERRER):…………………………………………………….
SIGNATURE (YOUNG PERSON):………………………………………………………….
DATE:
Please return completed Referral Forms by post or e-mail or Fax:
The Youth Team
Seymour House
MountWise
Plymouth
PL1 4JQ Tel: 01752 566104 e-mail: Fax: 01752566101
We may share information with other professional agencies in order to enhance our positive intervention or to protect an individual who may be in danger of serious harm.

SEYMOUR HOUSE YOUNG PEOPLES SERVICE

YOUNG PERSONS DETAILS (FOR HH USE) CLIENT CODE:
NEXT OF KIN / FAMILY DETAILS:
(Do you think they would like to visit, see the building and spend time with the young person?)
NAME: Yes No
ADDRESS: TELEPHONE NO.:
POST CODE:
DOCTORS DETAILS:
NAME:
ADDRESS: TELEPHONE NO.:
POST CODE:
MEDICAL CONDITIONS/MEDICATION/ALLERGIES OR DIETARY INFORMATION.

SCHOOL DETAILS:

SCHOOL NAME:
ADDRESS: TELEPHONE NO.:
POST CODE:
PRESENTING ISSUES: HOBBIES, INTERESTS AND RECREATIONAL ISSUES:
AGENCY / DEPARTMENT WHICH WILL BE FUNDING YOUNG PERSON’S PLACEMENT :
NAME:
ADDRESS: TELEPHONE NO.:
POST CODE:
WE WILL BE REVIEWINGTHE YOUNG PERSONS CARE PLAN WITHIN A SIX WEEK PERIOD, WITHTHIERREFERRERS. (Agree date and time at the point of assessment)

Day Programme

Consent Form

First name: Surname:

Address:Date of birth:

Age:

Telephone:

Post Code

Medical conditions/medication/allergies or dietary information:

Can the young person swim 10 metresYES/NO

Emergency contact (please ensure that the persons named are contactable)

Name:Telephone:

Mobile:

Relationship to young person:

GP Name:GP Telephone:

GP Address:

I give permission for my son/daughter to participate activities.

I also understand that it is my responsibility to advise Seymour of any changes to the above information.

I give permission for my son/daughter to

  • Receive any necessary medical treatment
  • Have their photos taken and used in local publications

As part of our programme we will be off site on various trips. Where necessary we will inform you of these. This form will act as a consent for these trips.

Signed:Name: Date:

(parent/guardian)

SEYMOUR HOUSE YOUNG PEOPLE REFERRAL FORM15/02/2010