Harrow Referral Form - The wïsh centre

Referrer

Heads Up

If you have come via heads up, please tick this box.

Referrer Details

Referral Type *

Referral Date

Referral - Other *

Name *

Job Title

Organisation

Organisation (Health)

Organisation (School)

Organisation (Social Care)

Organisation (Statutory/Voluntary)

Organisation (Other)

Contact Number *

Additional contact number

Email *

Young Person

Young Person Details

Name *

Has the young person consented to this referral? *

Yes

No

Date of Birth *

Gender *

Religion

Gender - Other

Religion - Other

Contact Number *

Ethnicity *

Etnicity - Other

Email

Sexuality

Sexuality - Other *

School / College / Job / Not Employed / Training: -Please state which *

Disability

If the young person considers themselves to have a disability please select the most appropriate definition. If the young person has multiple disabilities please select the definition that reflects the predominant disability.

Disability

Disability - Other *

Additional

Young Person Additional Contact Details

House Name/No and Road *

Town/City *

Postcode *

Is it Ok to contact Young Person directly? *

Yes

No

Is it Ok to leave a telephone message? *

Yes

No

Safe Emergency Contacts

(Must be over 18 and at least one to be in the current household.)

Safe Emergency contact no.1 Name/ phone *

For digital support, under 18s will need parental consent. Have the parent/carers been informed about the referral? *

Yes

No

If no, please state why.

Please state who is in the current household with you: *

Please be aware if the young person is under 14 disclosures may have to be made.

Referral

Which programme are you referring yourself to?

(tick all that apply)

Outreach- up to four sessions to discuss my options

Therapy- 1:1 open ended therapy sessions

Peer Support – A weekly non-judgemental space to make friends and learn new coping mechanisms, facilitated by a staff member

Art Therapy Group

Is the young person currently living with the DV perpetrator?

Yes

No

Please state reasons for referral *

Is the young person/you taking any medication? *

Yes

No

Further details

Does the young person/you have a clinical diagnosis? *

Yes

No

Further details

Has the young person/you made any suicide attempts or been hospitalised? *

Yes

No

Further details

Does the young person/you have a recent history of violence or aggressive behaviour toward others? *

Yes

No

Further details

Has the young person/you been to A&E for Self Harm in the last 12 months? *

Yes

No

How many times? *

Are there any known associated risks e.g. Domestic/Honour-based violence? *

Yes

No

Further details

Is the young person/you a Class A drug user? *

Yes

No

Further details

Is the young person/you or family members on a Child in Need plan? *

Yes

No

Further details

Are you or any family members on a Child Protection Plan *

Yes

No

Further details

Has the young person/you been a victim of sexual violence/exploitation? *

Yes

No

Further details

Intervention details

Please add details of the intervention(s):

Organisations or workers involved

Please name any other organisations or workers involved in the the clients welfare:

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Referrer

Referrer Details

Young Person

Young Person Details

Disability

Additional

Young Person Additional Contact Details

Referral

Referral