Key Unlocking Futures Referral Form
Date Received (office use only)
Referral Application Date
(This line, office use
only)
Support Start
Date
Database Ref (office use only)
Case
Number
Support
End Date
Evaluation
Complate
Yes
No
If you have any enquiries or require support to complete this form please phone: 01772 678979
Service
Requested
(You can
request more
than one )
Mediation/Anger
Management
Counselling
Employment
/Training
Coaching
Please ring Rosie
01772678979
Nest
(Young Victim)
Family Support
Please request a referral
form 0300 111 0323
Please request a referral form
[email protected]
Applicant
Date of Birth
Name
CAF Number
Current address
Male or female
Contact Details, Landline,
School Details
Mobile, Email address
include contact name
Parents Details
Name:
Contact details:
Family/Young Person
(if a young person)
Yes
NO
Consent (essential)
Referring Agency
Name of referrer
Agency Name
Referrers address,
contact details
Relevant Information/Reasons For referral
Current/Past Support
Has the applicant received support from any of the following agencies:
Social Services
Substance Misuse
Mental Health
Other (Please state)
Probation / YOT
Please provide details of any current support services that may support you. And please add details and addresses of other family members who
may be relevant to this referral
Name:
Relationship/Nature of support:
Agency
Contact Details
Name:
Agency
Contact Details
Relationship/Nature of support:
July 2016 Key Telephone 01772678979
Assessment of Risk
To help this process, you or your referring agency are required to complete the matrix below to indicate any known
risks associated with this application. Please give brief details in boxes:
No Problem
Past Issue
Current Issue
Violence & Aggression
Mental Health
Finance / Debt
Self-Harm /
Injurious behaviour
Self-neglect / lack of personal care
Drug/Alcohol Misuse
Other Addictions e.g. Gambling
Sexual assault
Anti-Social behaviour
Consent to Share Declaration
I give my permission to obtain and share further information from relevant agencies which may include, for example, DWP, Social Services,
Schools, Police, Probation Services, Local Authorities, Housing Associations.
I/We declare that to the best of my/our knowledge and belief, the information given is correct.
I/We understand that it is an offence to give false or misleading information.
I understand that this may mean requesting information covered by the DATA Protection Act 1998 and I consent to the sharing of this information.
I understand that information collected by KEY is kept on a database so only members of KEY staff are aware of the case and statistical information
can be collated.
Applicant (person referred) Name:
Applicant (person referred) Signature:
Parents Signature: (where applicable (i.e. young person)
Date:
Please return this to Key Unlocking Futures either by mail, e-mail or in person.
Unit 2, Balfour Court, Leyland, PR25 2TF
[email protected]
July 2016 Key Telephone 01772678979
Equality and Diversity Monitoring
Key Unlocking Futures aims to promote equality and inclusion to ensure fair access to the service in line
with the Equalities Act 2010. These questions are used to monitor access to the service and are not used
to make decisions (things like an applicant’s ethnicity) on eligibility or allocation. Key Unlocking Futures will
not discriminate unlawfully, our Equality Policy is available on request.
How would you describe your Ethnic origin? (Please indicate one)
White: British
Asian/Asian British: Bangladeshi
White: Irish
Asian/Asian British: Other
White: Other
Black/Black British: Caribbean
Mixed: White & Black Caribbean
Black/Black British: African
Mixed: White & Black African
Black/Black British: Other
Mixed: White & Asian
Chinese/ Chinese
Mixed: Other
Chinese/Other
Asian/Asian British: Indian
Other ethnic origin
Asian/Asian British: Pakistani
Do not wish to disclose
How would you define your religion? (Please indicate one - optional)
None
Christian (all Christian denominations)
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other religion
Not known
Do not wish to disclose
Please indicate your nationality (country of citizenship)? Please tick one box
only:
UK national resident
in UK
Other EU country (
state)
Other country
(state)
UK national returning
from living overseas
Do not wish to
disclose
Marital Status
Married
Single
Divorced/ Separated
Civil Partnership
Widowed
Prefer not to say
Gender
Male
Female
Transgender
Other
Prefer not to say
Sexuality
Heterosexual
Homosexual
Bisexual
Other
Prefer not to say
Do you consider yourself to be disabled
Are you pregnant or given birth in the last 6 months
Yes
Yes
July 2016 Key Telephone 01772678979
No
No