Name and contact details of person making the referral : Relationship to YP: Date of referral: Has the young person given their consent for a referral to be made? (please note we require YP consent for referral to be accepted) Are the person’s parents/carers aware of this referral? (please note parental/carer consent is not essential for a referral to be accepted) Name of young person: Is the person: (complete/highlight/delete as appropriate) Attending school DOB: Age: Attending college Address Excluded from school Employed Unemployed In training Who does the young person live with? Family Friends NFA Not Known Other: Receiving Mental Health treatment? In contact with Offending Team? Contact Tel numbers: Looked Care? (own / parents / relative?) (own / parents / relative?) Do any of the young person’s parents/siblings or significant Can we contact the YP at home address? Yes No others use substances? Gender: Ethnicity: Are there any Child Protection or safeguarding issues? Y/N Does the young person have any learning difficulties or If yes, please detail below: disabilities? Yes No Details: Pregnant? A parent? Substances used Route e.g smoke Amount e.g £, bags, cans, bottles Frequency e.g daily, 2/7, binge (effects after substance use, risk to worker, physical/mental health risks, OTHER RELEVANT INFO/IDENTIFIED RISKS offending, overdose etc) . details of agencies/professionals involved of GP School/College Youth Social Services Offending CAMHS Other (Final section for office use only) Date received Date allocated Allocated Worker John Tiernan House, 92 102 Ribble Road, Platt Bridge, Wigan, WN2 5EL, Tel No. 01942 865591 – E Mail or if sending from a secure e mail address,
Name and contact details of person making the referral : Relationship to YP: Date of referral: Has the young person given their consent for a referral to be made? (please note we require YP consent for referral to be accepted) Are the person’s parents/carers aware of this referral? (please note parental/carer consent is not essential for a referral to be accepted) Name of young person: DOB: Age: Address Who does the young person live with? Family Friends NFA Not Known Other: Contact Tel numbers: (own / parents / relative?) (own / parents / relative?) Can we contact the YP at home address? Yes No Gender: Ethnicity: Does the young person have any learning difficulties or disabilities? Yes No Details: Pregnant? A parent? Is the person: (complete/highlight/delete as appropriate) Attending school Attending college Excluded from school Employed Unemployed In training Receiving Mental Health treatment? In contact with Offending Team? Looked Care? Do any of the young person’s parents/siblings or significant others use substances? Are there any Child Protection or safeguarding issues? Y/N If yes, please detail below: Substances used Route e.g smoke Amount e.g £, bags, cans, bottles Frequency e.g daily, 2/7, binge OTHER RELEVANT INFO/IDENTIFIED RISKS (effects after substance use, risk to worker, physical/mental health risks, offending, overdose etc) . details of agencies/professionals involved of GP School/College Youth Offending Social Services CAMHS Other (Final section for office use only) Date received Date allocated Allocated Worker John Tiernan House, 92 – 102 Ribble Road, Platt Bridge, Wigan, WN2 5EL, Tel No. 01942 865591 E Mail or if sending from a secure e mail address,
tier_3_referral_form__0.docx