Our Voice Referral form

Details of Young Person

Full Name:

Mobile (if appropriate):

Address:

Postcode:

Consent for referral:

Young Person YesNo

Parent/Guardian (if required) YesNo

Details of Parent/Guardian

Address (if different from above):

Postcode:

Telephone Number:

Email Address:

Details of Referrer

Full Name:

Agency:

Job Title:

Telephone:

Email*:

Address:

Postcode:

Details of Social Worker

Full Name:

Telephone:

Email*:

About the child/young person:

Is the child/young person in a settled placement? YesNo

How long has the child/young person been in this placement?

What work has already been undertaken with the child/young person or family?

Is the child/young person currently accessing support via CAMHS/ELCAS (or other statutory mental health services) YesNo

Are any other agencies involved? YesNo

Please detail

Is the child/young person displaying any self-harming behaviours? YesNo

If YES please provide detail (severity/duration)

Is the child/young person experiencing suicidal ideation? YesNo

If YES please provide detail (plan/intent/history)

Reason for referral

What is the desired outcome you would like the CYP to achieve from this support?

Privacy options:

I confirm I have read the privacy policy

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Our Voice

Key contacts

Details of Young Person

Consent for referral:

Details of Parent/Guardian

Details of Referrer

Details of Social Worker

About the child/young person:

Reason for referral