Minutes of the Meeting Which Identified This Referral As the Appropriate Way Forward Are

A.B.E.L.

Referral Form

Brunton Hall

Ladywell Way

Musselburgh

EH21 6AF

APPENDICES:-

Minutes of the meeting which identified this referral as the appropriate way forward are attached. 

Details Of Organisation

Making The Referral

Name of contact ………………………………………………………………………………….

Name and address of referrer ………………………………………………………………..

……………………………………………………………………………………………………..

……………………………………………………………………………………………………..

Tel No ………………………………………

E-mail address …………………………………………………………………………………….

Date of referral …………………………………………………………………………………...
Referral

Please note that ABEL operates an OPEN ACCESS POLICY and the information you give on this form will be shared with the young person and their parents/carers.

1. General Information

Name of child/young person …………………………………………………………………..

School ………………………………………Class ……….. D.O.B. ……………………….…

Class/Guidance Teacher …………………………………………………………………….….

Family composition …………………………………………………………………………….

…………………………………………………………………………………………………..

…………………………………………………………………………………………………..

Position in Family: ………………………………………… Male Female

Name and address of Parent(s)/Carer(s) ………………………………………………………..

…………………………………………………………………………………………………...

…………………………………………………………………………………………………...

Home Tel No ……………………………….. Work Tel No ……………………….………….

Email Address ………………………………………………………………………………….

Emergency Contact Name ……………………………………………………………..…….…

Home Tel No ……………………………….. Work Tel No …………………………………..

1. Permission

See pages 4 & 5, information sheet for parents and following page

‘Permission for this referral has been given’ and ‘Consent to information being shared’both sections have to be completed by the young person and parent/carer before the referral can be processed.

INFORMATION ON PERMISSION TO WORK WITH ABEL & INFORMATION SHARING:

Why do we need parents and young person’s permission for the referral to be made?

It is important that parents and young people are aware that a referral is being made. And that they agree with the reasons for that referral and are prepared to work with ABEL.

Why does ABEL need to share information with the young person’s school and other agencies?

ABEL works closely with schools and sometimes different agencies to provide the help the young person needs.

To do this, information may need to be shared between schools, agencies and organisations to:

make sure that parents, carers and the young person are getting the help that they need

make sure that services are provided in a joined up way

cut down the number of forms parents and carers need to fill in

provide services that are focused on the needs of the young person and their family

make sure that the young person’s carers’ and parents legal rights are protected

make sure that services are tailored to the needs of individual young people and their families

It is important to protect people’s rights to confidentiality (Copies of ABEL’s confidentiality policy, statement of rights and code of practise can be requested from our office) Information will only be shared with other agencies when it will help them to provide a service to a young person or his/her family.

If a young person is believed to be capable of understanding the consequences of confidentiality, their consent is required for disclosure or access to records. A young person of 12 or over is normally assumed to have sufficient understanding.

You may refuse to allow information to be shared with others. If information cannot be shared, it may take longer to provide the services needed or it may not be possible to provide the full range of services needed.

However, if it is believed that a young person is at serious risk, information must be shared with other agencies. We would normally tell you in this situation, unless this would be felt to increase the risk to the young person.

If you agree that information can be shared about you or the young person, please fill in the form on the next page. The person who has completed this form with you will explain what happens next.

CONSENT TO REFERRAL

I agree to this referral being made. I understand that I may change my mind about this at any time. If I do, I will contact either ABEL or the person who sent the referral, as soon as possible.

Permission for this referral has been given

By young personYesNoSignature ……………………..

By Parent/CarerYesNoSignature ……………………..

CONSENT TO SHARE INFORMATION

I agree to information being shared if needed with doctors, teachers, health visitors, social workers, and agreed others. I understand that I may change my mind about this at any time. If I do, I will advise my ABEL worker.

I understand that the information shared will be used to provide health, education and welfare services in the best interests of myself /young person.

I understand that personal records are protected by various laws and cannot be disclosed without written consent, unless otherwise authorised (in cases where someone is at serious risk). I have received and understand information on confidentiality and information sharing.

Consent to information being shared

By young personYesNo Signature ……………………..

By Parent/CarerYesNo Signature ……………………..

It is important for this page to be completed as ABEL is unable to start work with the young person until it is received.

Please note that both sections must be completed by the young person and parent/carer before the referral can be processed.

1. Status

Level of intervention 1 2 3

Is the young person working voluntarily with the Social Work Department?

Yes No

Name of Social Worker …………………………...…………… Tel No ……..….…..………

Does the young person receive support from any other agency?

YesNo

If yes please specify ……………………………………………..………….………….…...…..

…………………………………………………………………………………………..……….

Name of Educational Psychologist …………………………….. Tel No ………...…..………

Date of next Multi-Agency Meeting …………………………………………………………..

1. Causes for Concern

To be completed by referrer

(Reasons for referral. Please answer the following by scaling all that apply from a scale of 1-10. 1 being things are their worst – 10 being things are going well)

1. Information regarding situation

1. Any further appropriate information which would support our work with this child.

Thank you for taking the time to fill this referral form

out fully, as this will enable us to assess the appropriate support required.

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