Referral Form /
Screening Tool
Part 1: To be completed by the Referrer
Section 1: Information about the Child / Young Person
Name:
Date of Birth:
Gender:
Address:
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☐ Male / ☐ Female / ☐ Other
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Postcode:
Home Tel:
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Other name:
Age:
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Mobile Tel: >
Ethnic Classification (based on 2001 census):
White
☐ British
☐ Irish
☐ Other White
Black / Black British
☐ Caribbean
☐ African
☐ Other Black
Asian / Asian British
☐ Indian
☐ Pakistani
☐ Bangladeshi
☐ Other Asian
Chinese / Other Ethnicity
☐ Chinese
☐ Any Other
Mixed
☐ White / Black Caribbean ☐ White / Black African ☐ White / Asian
☐ Other Mixed
Information not obtainable: ☐
Health:
GP Name: >
Address: >
Are there any physical or emotional health concerns or diagnoses? ☐ Yes / ☐ No
If yes, please add details:
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Family Details
Mother: >
Father: >
Other: >
Address (if different):
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Address (if different):
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Address (if different):
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Tel: >
Tel: >
Tel: >
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Other Children in Household
1.
Name:
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Gender: ☐ Male / ☐ Female
Age
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Relationship: >
4.
Name:
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Gender: ☐ Male / ☐ Female
Age
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Relationship: >
2.
Name:
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Gender: ☐ Male☐ Female
Age:
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Relationship: >
5.
Name:
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Gender: ☐ Male / ☐ Female
Age:
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Relationship: >
3.
Name:
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Gender: ☐ Male☐ Female
Age:
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Relationship: >
6.
Name:
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Gender: ☐ Male / ☐ Female
Age:
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Relationship: >
Social Care
Please include brief details of any current or previous social care involvement with any
child, or adult, mentioned above
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Other Agencies
Please include details of any known agencies working with the child / young person
1. Organisation:
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Allocated Worker: >
Address:
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2. Organisation:
Allocated Worker:
Address:
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Education
Name of of school (or other educational establishment):
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Address: >
Main contact at school:
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Tel:
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Is the child receiving support under the SEN Code of Practice? ☐ Yes / ☐ No
Is there an EHC Plan? ☐ Yes / ☐ No
Does the child require additional provision in school? ☐ Yes / ☐ No
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Section 2: Risk and Protective Factors to Offending / Anti-Social Behaviour (ASB)
Please select as many factors as you believe apply to the child / young person being referred and
provide evidence for each.
1. Individual
Risk:
☐ Gets into trouble in school / at home / in community
☐ Risk-taker
☐ Runs away from home / Truant
☐ Aggressive / Angry
☐ Self-harmed / attempted suicide
☐ Uses alcohol / substances
☐ Positive attitude to / involvement in ASB / crime
☐ Lack of guilt / empathy
☐ Struggles emotionally (low self-esteem; worries about past / future)
Protective:
☐ Low impulsivity
☐ Knows right and wrong
☐ Positive attitude (helpful and co-operative)
Evidence and/or any other relevant information:
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Family
Risk:
☐ Moved a lot / Different carers
☐ Family resolve issues with aggression
☐ Poor supervision / Lacks boundaries
☐ Child / YP experienced abuse / violence in the home
☐ Parents require additional support
☐ Parent / Carer has health (including mental) issues
☐ Parent / Carer misusing alcohol or drugs ☐ Family member(s) involved in ASB / crime
Protective:
☐ Stable family structure
☐ Infrequent parent / child conflict
☐ Appropriate supervision and discipline
Evidence and/or any other relevant information:
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School
Risk:
☐ Poor attitude to school
☐ Low academic achievement in school
Protective:
☐ Academic achievement
Evidence and/or any other relevant information:
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☐ Excluded from school
☐ Learning disability
Peer Group
Risk:
☐ Friends involved in ASB / crime
☐ Poor relationships with friends
☐ Friendship group has changed
Protective:
☐ Has some friends not involved in ASB / crime
Evidence and/or any other relevant information:
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Community
Risk:
☐ Disadvantaged neighbourhood
☐ Use of weapons / drugs in the neighbourhood
Protective:
☐ Affluent neighbourhood
Evidence and/or any other relevant information:
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☐ Does not feel safe in neighbourhood
☐ High levels of youth ASB / crime
Harmful Sexual Behaviour - only to be completed if you have concerns in this area
Evidence and/or any other relevant information?
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Section 3: Reasons for Referral
What is working well for the child / young person and family?
This section should focus on strengths and protective factors within the family.
How will these actually improve the situation?
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What are we worried about?
What are the key issue and difficulties facing this child / young person and/or family?
What impact is this having on the child / young person and/or family?
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Next steps - what do we want to achieve, what needs to change and who needs to do it?
Based on your analysis, professional judgement and conversation with the family, what outcome
do we want to achieve and what needs to be done to achieve it? Include what you have agreed
with the family.
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Many thanks for completing this referral form.
Please add your details below and return the form to your YOS team
Name:
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Agency: >
Address: >
Email
Date: >
Tel:
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