Referral Form Child/Young Person Details 1. Child / Young Person First Name 2. Child / Young Person Last Name 3. Date of Birth 4. Gender identity of child/young person Male Female Non-binary Other Prefer not to say 5. NHS number 6. Child/Young Person Address Line 1 Child/Young Person Address Line 2 Child/Young Person City 7. Child/Young Person Postcode 8. Child/Young Person Ethnicity - Select Option - White - British White - Irish White - Gypsy White - Roma White - Irish Traveller White - Other Traveller White - Any other White background Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Any other mixed background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Any other Asian background Black or Black British - Caribbean Black or Black British - African Black or Black British - Any other Black background Other Ethnic Groups - Chinese Other Ethnic Groups - Any other ethnic group Not known 9. Child/Young Person School type - Select Option - Primary Secondary Specialist/ Alternative Provision Independent Further Education College 10. Child/Young Person School Name - Select Option - Does not attend school Abbey Court School All Faiths Children’s Academy Allhallows Primary Academy Barnsole Primary School Bligh Primary School Blue Skies School Bradfields Academy Brompton Academy Brompton-Westbrook Primary School Burnt Oak Primary School Bryony School Byron Primary School Cedar Children’s Academy Chatham Grammar Chattenden Primary School City of Rochester School Cliffe Woods Primary School Crest Infant School Cuxton Community Infant School Cuxton Community Junior School Danecourt School Deanwood Primary School Delce Academy Does not attend school Elaine Primary School English Martyrs’ Catholic Primary School Fairview Community Primary School Featherby Infant & Nursery School Featherby Junior School Featherstone Primary School Fort Pitt Grammar School Gordon Children’s Academy (Infant) Gordon Children’s Academy (Junior) Greenacre Academy Greenvale Primary School Halling Primary School Hempstead Infant School Hempstead Junior School High Halstow Primary Academy Hilltop Primary Academy Holcombe Grammar School Hoo St Werburgh Primary School Horsted Infant School Horsted Junior School Inspire Free School King’s School, Rochester Kingfisher Community Primary School Leigh Academy Hundred of Hoo Leigh Academy Rainham Leigh Academy Strood Luton Primary School Maritime Academy Maundene School Midkent College MidKent College (Medway Campus) Miers Court Primary School Napier Primary Academy New Horizons Children’s Academy New Road Primary School Oasis Academy Skinner Street Parkwood Primary School Peninsula East Primary Academy Phoenix Primary School Rainham Mark Grammar School Rainham School for Girls Rivermead School Riverside Primary School Rochester Independent College Rochester Riverside Church of England Primary School Saxon Way Primary School Sir Joseph Williamson’s Mathematical School St Andrew’s School St Augustine of Canterbury Catholic Primary School St Helen’s Church of England Primary School St John Fisher Catholic Comprehensive School St Margaret’s Church of England Junior School St Margaret’s Infant School St Mary’s Catholic Primary School St Nicholas Church of England Infant School St Nicholas Church of England Junior School St Peter’s Infant School St Peter’s Junior School St Thomas More Catholic Primary School St William of Perth Catholic Primary School Swingate Primary School The Howard School The Robert Napier School The Rochester Grammar School The Rowans Alternative Provision Academy The Thomas Aveling School The Victory Academy Trinity School and College Twydall Primary School and Nursery Walderslade Primary School Walderslade School Warren Wood Primary Academy Waterfront UTC Wayfield Primary School Will Adams Academy Woodlands Primary School Referrer Details 8. Referrer First Name 9. Referrer Surname 10. Referrer School/Organisation 11. Referrer Contact Number 12. Referrer Email Parent/Carer DetailsPlease add parent/carer details if they differ from the referrer details 13. Parent/Carer Name 14. Parent/Carer Number 15. Parent/Carer Email 16. Consent to contact parent/carer? Yes No 1. Type of support required Drop-in session Group Support Programme Individual Support Programme One-off workshop/ group session Other If Other, please specify 2. Preferred organisation to provide support (Please select at least one) North Kent Mind Young Lives Foundation Salus CHUMS Barratt Behaviour Change Consultancy Oasis 3. Which areas best describe the main concerns? (Select all that apply) Emotional Wellbeing Risk and Safety Behavioural Concerns Identity and Belonging Relationships and Family Neurodivergence and SEND Bereavement or loss Other If other, please specify 4. Reasons for Referral (please include as much detail as possible in order for us to allocate the best support) 1. Does the child/young person have a diagnosed disability or additional needs? Yes No Not known 2. Name of diagnosis - Select Option - Special Educational Needs (SEN) Learning Disability Autism / ASD Physical Disability Visual Impairment Hearing Impairment Long-term Health Condition Mental Health Condition Hidden - ASD/ADHD Hidden - Other Undiagnosed/Awaiting Diagnosis (SEN) Other Disability (please specify) Other Disability (please specify) 3. Does the child/young person have an Educational Health Care Plan (EHCP)? Yes No Not known 4. Is the child/ young person part of a priority referral group? - Select Option - Looked after child (including UASC) Care Leaver Youth justice experienced Unaccompanied asylum seeker None of the above 5. Social Worker Name 6. Social Worker Number 7. Social Worker Email 8. Youth Justice Worker Name 9. Youth Justice Worker Number 10. Youth Justice Worker Email 11. Are there any safeguarding concerns we should be aware of? Yes No Not known 12. Safeguarding details if applicable: 13. Are there any reasonable adjustments we need to be aware of? (e.g. communication needs, support preferences etc.). 14. Is there anything else we should be aware of? Send
