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ALP: One to One Support Referral Form
Please tick which is appropriate for your referral:
(required)
Please tick a checkbox
I’m making a referral for 1-2-1 support
I’m making a referral into the off-site small group provision as a spot purchase for an individual student
Referrer’s name
(required)
This field is required
Relationship to young person
(required)
This field is required
Referrer’s contact address
(required)
This field is required
Referrer’s telephone
(required)
This field is required
Referrer’s mobile
Referrer’s email
Please tick the boxes to confirm that:
As referrer you agree to be available for contacting regarding this referral by CYN for a period of two weeks after receipt of referral
The YP agrees to be referred and engage with support
The YP named is aware of the referral
Young person’s details
Young person’s name
(required)
This field is required
Has the young person ever been known by any other name? If YES please state
Home address
(required)
This field is required
Date of birth
(required)
Please select a date
Young person’s number
(required)
This field is required
Young person’s email
(required)
This field is required
Gender
(required)
Male
Female
Transgender
Non-binary
Prefer not to say
Other
In-Care/ Care leaver
Yes
No
Young carer
Yes
No
Primary carer 1: Name
(required)
This field is required
Primary carer 1: Telephone/mobile/email
(required)
This field is required
Primary carer 1: Relationship to young person
(required)
This field is required
Primary carer 2: Name
(required)
This field is required
Primary carer 2: Tel/mobile/email
(required)
This field is required
Primary carer 2: Relationship to YP
(required)
This field is required
If the YP named above is under 13 years of age, parents/carers need to be aware of the referral.
(required)
Please tick a checkbox
YP is aged 13 and over
YP is under 13, and parents are aware of the referral
Details of any LDD or other disability
Current risk factors youth workers should be aware of (e.g. Violence, drug use, dangerous pets in the house etc.)
Other agencies involved currently/ in recent past with this young person and/or family that we should know about (please include name of org, details of worker, nature and duration of support, and reason for it ending)
Has the young person experienced any Adverse Childhood Experiences (ACEs)? Mark all that apply:
Physical abuse
Sexual abuse
Emotional abuse
Living with someone who abused drugs
Living with someone who abused alcohol
Exposure to domestic violence
Living with someone who was incarcerated
Living with someone with serious mental illness
Parental loss through divorce, death or abandonment
Asylum seeker or refugee
None of the above
Please provide details on the above if applicable:
Referral details: The following boxes must be completed in full for the referral to be assessed
Please state the reasons for the referral
(required)
This field is required
Of the following ALP 121 offer, which is most suitable for the YP? (Tick all that apply):
(required)
Please tick a checkbox
Wellbeing
Physical health
Sexual health
Drug/alcohol abuse
ASB/Youth offending
Education, employment or training
Other
If other, please explain below:
What does the referrer hope this intervention will achieve?
Young persons views and expectations on the referral - What support would the YP like to access?
What are the YP’s hobbies or interests? Any other relevant/useful information
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