Our Voice

Our Voice is one Voice – Hearing the voices of children and teenagers in care.

Please complete the referral form here. So that contact can be actioned quickly please ensure you complete as much of the information as possible.

Fields marked with an * are required.

Key contacts

Tel: 01254 692709
Email: EHWBReferrals@canw.org.uk

Details of Young Person

Full Name:

DOB:

Age:

Mobile (if appropriate):

Address:

Postcode:

Consent for referral:

Young Person YesNo

Parent/Guardian (if required) YesNo

Details of Parent/Guardian

DOB:

Age:

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?

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