In your professional opinion, is the Child/YP safe and supported enough to be able to attend therapy sessions where there is a Yes: No: Unsure: likelihood of deteriorating behaviour during the process? Is the Child/Young Person willing to attend sessions? Yes: No: Unsure: Has the child/young person been referred to the project in the Yes: No: Unsure: past? Is the Child/Young Person related or in any way connected to Yes: No: Unsure: any child/young person who has been referred to this project? If yes, please give details: The service we offer may include a home assessment. Please state, where applicable, any issues or concerns that we may need to know in advance: In signing this referral you are consenting to Fresh Start new beginnings setting up a case file, and processing – the referral in order to be considered for receiving a service from us. You are also giving consent for us to contact other professionals who are, or have been, involved with the young person or yourselves (for the purpose of sharing information), and you are also agreeing to us undertaking a risk assessment, should this be necessary. In signing this referral form you also understand that Fresh Start new beginnings do not hold case – responsibility at any time. Signature of referrer: Date: Signature of Young Person Date: agreeing to referral: Signature of Parent/Carer Date: agreeing to referral: A signature from a parent/carer is required for all referrals. If you are also referring a parent/carer please complete Appendix 1. If you are referring a sibling who has been affected but not abused themselves please complete Appendix 2. PLEASE ATTACH RELEVANT REPORTS AND CASE CONFERENCE MINUTES Fresh Start - new beginnings Please return form to: Head Office 333 Felixstowe Road Ipswich Suffolk IP3 9BU Contact details: Telephone: 01473 353355/01603 558205 Email: admin@fsnb.org.uk Website: www.fsnb.org.uk
In your professional opinion, is the Child/YP safe and supported enough to be able to attend therapy sessions where there is a likelihood of deteriorating behaviour during the process? Yes: No: Unsure: Is the Child/Young Person willing to attend sessions? Yes: No: Unsure: Has the child/young person been referred to the project in the past? Yes: No: Unsure: Is the Child/Young Person related or in any way connected to any child/young person who has been referred to this project? Yes: No: Unsure: If yes, please give details: The service we offer may include a home assessment. Please state, where applicable, any issues or concerns that we may need to know in advance: In signing this referral you are consenting to Fresh Start – new beginnings setting up a case file, and processing the referral in order to be considered for receiving a service from us. You are also giving consent for us to contact other professionals who are, or have been, involved with the young person or yourselves (for the purpose of sharing information), and you are also agreeing to us undertaking a risk assessment, should this be necessary. In signing this referral form you also understand that Fresh Start – new beginnings do not hold case responsibility at any time. Signature of referrer: Date: Signature of Young Person agreeing to referral: Date: Signature of Parent/Carer agreeing to referral: Date: A signature from a parent/carer is required for all referrals. If you are also referring a parent/carer please complete Appendix 1. If you are referring a sibling who has been affected but not abused themselves please complete Appendix 2. PLEASE ATTACH RELEVANT REPORTS AND CASE CONFERENCE MINUTES Please return form to: Fresh Start - new beginnings Head Office 333 Felixstowe Road Ipswich Suffolk IP3 9BU Contact details: Telephone: 01473 353355/01603 558205 Email: admin@fsnb.org.uk Website: www.fsnb.org.uk