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 7. Child/Young Person Postcode 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. Organisation providing support Organisation providing support 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) 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 Special Educational Needs (SEN) Learning Disability Autism / ASD Physical Disability Visual Impairment Hearing Impairment Long-term Health Condition Long-term Mental Health Condition 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? Looked after child (including UASC) Care Leaver Youth justice experienced 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
