Parent/Carer Name: Phone Number: Email: Reason for Referral: Would young Male  Female person prefer a  No Preference  male or female befriender? Young person and Contact Parent parent/carer are  Contact Young Person  aware of referral and are happy for Any other information? us to make contact. Date: For Office Use: Date received: Risk Assessment rec’d: Date Assessed: Funding agreed: Service Agreed: Support Plan and Risk Assessment Young Person’s Name: Completed by: Date:
Parent/Carer Name: Phone Number: Email: Reason for Referral: Would young person prefer a male or female befriender?  Male  Female  No Preference Young person and parent/carer are aware of referral and are happy for us to make contact.  Contact Parent  Contact Young Person Any other information? Date: For Office Use: Date received: Risk Assessment rec’d: Date Assessed: Funding agreed: Service Agreed: Support Plan and Risk Assessment Young Person’s Name: Completed by: Date:
B1-b-Buckinghamshire-Mind-Youth-Befriending-Referral-Form-updated-Oct.-2016.docx