What is their sexual Heterosexual/ straight orientation? (if age appropriate) Gay woman/ Lesbian Gay man Bisexual (please specify): Don’t Know Children/teenagers support needs/ vulnerabilities Please tell us more about any support needs the child/teen may have: Mental Health Issues with educational attainment/ Physical Health attendance Sexual Health Social isolation Substance misuse Bullying/ being bullied Aggressive behaviour Experiencing abuse Self-harming/ suicidal feelings Other (please specify below) Additional details: 5. Household Composition Please provide names and Date of Birth for any members of the household, including siblings below: Name DOB Perpetrator’s Details Please provide name, address, date of birth (if known) of any perpetrators and details of their relationship to the child Name Address DOB Relationship to child
What is their sexual orientation? (if age appropriate) Heterosexual/ straight Gay woman/ Lesbian Gay man Bisexual (please specify): Don’t Know Children/teenagers support needs/ vulnerabilities Please tell us more about any support needs the child/teen may have: Mental Health Physical Health Sexual Health Substance misuse Aggressive behaviour Self-harming/ suicidal feelings Issues with educational attainment/ attendance Social isolation Bullying/ being bullied Experiencing abuse Other (please specify below) Additional details: 5. Household Composition Please provide names and Date of Birth for any members of the household, including siblings below: Name DOB Perpetrator’s Details Please provide name, address, date of birth (if known) of any perpetrators and details of their relationship to the child Name Address DOB Relationship to child
CAT-referrl-form.docx