FORM-PS Referral form - Potton Social Care Services

Please confirm this is the form you require POTTON SERVICES REFERRAL.

Please provide details of all children/young people being referred

Child /Young person Local Authority ID Number

Child /Young person Gender/Identifie s as (pronoun)

Child /Young person Forename

Child /Young person Ethnicity

Child /Young person Surname

Child /Young person Religion

2nd Child /Young person Date of birth

Child /Young person Language

2nd child/young person being referred

2nd Child /Young person Local Authority ID Number

2nd Child /Young person Gender/Identifie s as (pronoun)

2nd Child /Young person Forename

2nd Child /Young person Ethnicity

2nd Child /Young person Surname

2nd Child /Young person Religion

2nd Child /Young person Date of birth

2nd Child /Young person Language

3rd child/young person being referred

3rd Child /Young person Local Authority ID Number

3rd Child /Young person Gender/Identifie s as (pronoun)

3rd Child /Young person Forename

3rd Child /Young person Ethnicity

3rd Child /Young person Surname

3rd Child /Young person Religion

3rd Child /Young person Date of birth

3rd Child /Young person Language

4th child/young person being referred

4th Child /Young person Local Authority ID Number

4th Child /Young person Gender/Identifie s as (pronoun)

4th Child /Young person Forename

4th Child /Young person Ethnicity

4th Child /Young person Surname

4th Child /Young person Religion

4th Child /Young person Date of birth

4th Child /Young person Language

Home address of the child /young person

Full home address

Legal status

Select legal status

Other please detail.

Parents/Carers Details

Parent/Carer Relationship

Do they hold Parental Responsibility?

Parent/Carer Name

Parent/Carer Gender/Identifies as (pronoun)

Parent/Carer Contact Number

Parent/Carer Ethnicity

Parent/Carer Language

2nd Parents /Carers Details

2nd Parent/Carer Relationship

Do they hold Parental Responsibility?

2nd Parent/Carer Name

2nd Parent/Carer Gender/Identifies as (pronoun)

2nd Parent/Carer Contact Number

2nd Parent/Carer Ethnicity

2nd Parent/Carer Language

3rd Carers Details

3rd Parent/Carer Relationship

3rd Parent/Carer Do they hold Parental Responsibility?

3rd Parent/Carer Name

3rd Parent/Carer Gender/Identifies as (pronoun)

3rd Parent/Carer Contact Number

3rd Parent/Carer Ethnicity

3rd Parent/Carer Language

Temporary/Placement address

Temporary / Placement Full Address

Is this address confidential?

Foster/Temporary Carer Details

Foster/Temporary Relationship

Foster/Temporary Contact Number

Foster/Temporary Name

Foster/Temporary Language

Do they hold Parental Responsibility

2nd Foster/Temporary Carer Details

2nd Foster/Temporary Relationship

2nd Foster/Temporary Contact Number

2nd Foster/Temporary Name

2nd Foster/Temporary Language

Do they hold Parental Responsibility

3rd Foster/Temporary Carer Details

3rd Foster/Temporary Relationship

3rd Foster/Temporary Contact Number

3rd Foster/Temporary Name

3rd Foster/Temporary Language

Do they hold Parental Responsibility

Communication: Any Special Communication Needs? If yes please provide further details.

Communication Needs?

Other (Please provide details)

Referral Details

Name of referrer*

Role of referrer*

Telephone number of referrer*

Email address of referrer*

Name of Authorising Manager*

Date referred*

Date referred

About the child

Please give details of the child’s diagnosis.

Reason for Support Being Required.

Risk that may affect the young person and what triggers their behavior.

Promoting independence and realistic outcomes.

Young person’s view and what is important to them.

What makes them happy.

What are the young person’s hopes and dreams.

History of Case and Current Situation.

Doctors details

Doctors Name

Doctors Address

Doctors Telephone number

Social worker details

Name of social worker

Telephone number of social worker

Email address of social worker

Department of social worker

Placing Authority

Name of placing authority

Duty Number

Support Details **Please note, our minimum charge is 1 hour

Days/dates visits are required

Announced or Unannounced?

Time visits are required (if flexible please provide guideline – eg, anytime between 7am-6pm)

Are parents/carers aware of this referral?

Length of visit/s required**

Frequency of visits (please specify, weekly, monthly, one off etc)

_ _ _ _ _ _ _

Days/dates visits are required

Announced or Unannounced?

Time visits are required (if flexible please provide guideline – eg, anytime between 7am-6pm)

Are parents/carers aware of this referral?

Length of visit/s required**

Frequency of visits (please specify, weekly, monthly, one off etc)

_ _ _ _ _ _ _

Days/dates visits are required

Announced or Unannounced?

Time visits are required (if flexible please provide guideline – eg, anytime between 7am-6pm)

Are parents/carers aware of this referral?

Length of visit/s required**

Frequency of visits (please specify, weekly, monthly, one off etc)

_ _ _ _ _ _ _

Days/dates visits are required

Announced or Unannounced?

Time visits are required (if flexible please provide guideline – eg, anytime between 7am-6pm)

Are parents/carers aware of this referral?

Length of visit/s required**

Frequency of visits (please specify, weekly, monthly, one off etc)

Service Requirement

Proposed start date

Proposed end/review date

Work to be undertaken What is Potton Services role in this package?

Registered/Statutory Status: Please give details of name of child/young person, dates, category (if known)

Any child in family is/has been on the child protection plan?

Any child or other family member is/has been looked after by a local authority?

Any child in the family has a disability?

Any child in the family a Child in Care?

Any child in the family a Child in Need?

Any Current criminal proceedings?

Risk and Vulnerability Issues

Is it safe to visit the young person/Family at home? , if no please give further details.

Has the young person / family displayed any of the following behaviors? Please provide further details if Yes.

Verbally abusive behavior

Unpredictability due to substance misuse

Violent offences /behavior

Unpredictability due to mental health issues

Verbal abuse /threats towards agency staff

Sexual offences /sexually inappropriate behavior

Physical violence towards agency staff

Self-harm /attempted suicide

Racist /homophobic abuse or other hate crime

Other. Please Provide Details:

Please provide details of where invoices for this service should be sent (Please note, referral will not be accepted if this section is not completed)

Name of contact for invoicing*

Role of contact for invoicing

Department of contact for invoicing*

Email of contact for invoicing*

Telephone of contact for invoicing*

Authorisation

Authorising Manager*

Referral Date*

Referral Date