Team Meeting Dates T3 Walsall
Name:
Contact Number:
Address:
E Mail Address:
Role/Relationship to child:
Has the parent/carer given their consent for a referral to be made? Yes No
(please note we require parental consent unless the child is over 11 and able to self refer)
Is the Child aware of referral? Yes No Not Known
YP1details
Name of Child:
Date of Birth:
Ethnicity:
Address where child is currently living:
Contact Telephone number:
Lives with: parent/grandparent/other family/foster carer/other (delete as appropriate)
Is the child:
A young carer? Yes No
Affected by domestic violence? Yes No
Using substance themselves? Yes No
If yes, please provide details:
IF THERE IS MORE THAN ONE CHILD, PLEASE DETAIL ON PAGE 3 OF REFERRAL FORM / Parent details:
Name of parent(s):
Address of parent if not living with child:
Name and address of person who currently has parental responsibility (if not parent):
Child’s GP/Medical Details
GP name and address:
Details of any known medication/allergies/illness/disabilities:
School Details
School name and Address:
Contact name within school:
Status of Child
Child Protection Plan in place? / Child in Need? / Looked After? / Early Help? / Other / Route e.g smoke / Amount e.g £, bags, cans, bottles / Frequency e.g daily, 2/7, binge
Details of Parental/Carer Substance Use
Who / Substance being used / Frequency/Quantity / Is this person in treatment? / Any other info
RISK ASSESSMENT INFO:
Any relevant knowledge regarding the young person (i.e behaviour,aggression)
Any knowledge of family or significant other that could pose a risk
Any knowledge of risks in relation to home visit (i.e visitors to home, pets, paraphernalia etc)
details of other agencies/professionals involved of
Name / Agency / Contact details
Once complete please return to:
E Mail: or if sending via secure e mail account,
Post: YPDAS, John Tiernan House, 92 – 102 Ribble Road, Platt Bridge, Wigan, WN2 5EL
Tel No. 01942 865591
Additional Children – please use this section to enter details of additional childrenYP2
Name of Child:
Date of Birth:
Address (if different):
Ethnicity:
Is the child:
A young carer? Yes No
Affected by domestic violence? Yes No
Using substance themselves? Yes No
If yes, please provide details:
School Name and address (if different)
GP name and address (if different)
Details of any known medication/allergies/illness/disabilities:
Are parental details the same as YP1?
Any additional info:
YP3
Name of Child:
Date of Birth:
Address (if different):
Ethnicity:
Is the child:
A young carer? Yes No
Affected by domestic violence? Yes No
Using substance themselves? Yes No
If yes, please provide details:
School Name and address (if different)
GP name and address (if different)
Details of any known medication/allergies/illness/disabilities:
Are parental details the same as YP1?
Any additional info:
YP4
Name of Child:
Date of Birth:
Address (if different):
Ethnicity:
Is the child:
A young carer? Yes No
Affected by domestic violence? Yes No
Using substance themselves? Yes No
If yes, please provide details:
School Name and address (if different)
GP name and address (if different)
Details of any known medication/allergies/illness/disabilities:
Are parental details the same as YP1?
Any additional info: