KidsAid

Client ID*

Name of person completing the form*

Relationship to child/young person*

Comment*

Job Title*

Email Address*

Contact Number*

Full name of child/young person*

Is the child/young person aware that you are making this referral?

Please Explain*

The date of birth of the child/young person*

Age*

Gender*

Sexual Identity*

Ethnicity*

Religion

Nationality

First Language

Disability*

Please select the options below that most apply*

Is the young person taking medication?

Detail*

Residing address

First line of Address*

Second line of Address

Town*

County*

Postcode*

Address Type*

Comment*

Length of time living in residing home at time of referral

Number of homes the young person has lived in throughout their childhood

Is the child/young person currently receiving support under the following

Contact details of professionals involved:

Name of Social Worker*

Contact Number*

Email Address*

Name of Team Manager Not known

Contact Number

Email Address

Name of IRO Not known

Contact Number

Email Address

Details of Carer

Name*

Relationship To Child*

First line of Address*

Second line of Address

Town*

County*

Postcode*

Email*

Contact Number*

Add More

Are there any other services supporting this young person?

Name of Service*

Type of support being received*

Best contact at the service*

Consent to contact them*

Details of person (s) with parental responsibility

Name*

Relationship To Child*

First line of Address*

Second line of Address

Town*

County*

Postcode*

Email*

Contact Number*

Add More

Is there anyone who we should not communicate with?*

Name*

Relationship to young person*

Is there currently a family court case, or is there likely to be during KidsAid’s intervention?*

Detail*

Is the young person enrolled at school?*

Has the young person ever received any other form of therapeutic support?*

Primary Trauma*

Detail*

Secondary Trauma

Detail*

Length of time since trauma

Primary emotional difficulties experienced*

Detail*

Secondary emotional difficulties experienced

Detail*

Please describe trauma and difficulties experienced in more detail*

Is the young person considered to be a risk to themselves or others?

Comment*

Do parents/carers struggle with any of the following difficulties?

Detail*

Have parents/carers had support with this?

Do parents/carers require parent support sessions in addition to us supporting the child/young person?

Please give further information about what support would be beneficial?*

Have parents/carers had any parenting support before?*

Please advise support offered and where this took place*

What do you hope will be gained from our support for the young person?*

Is there a preference for type of therapy/ gender of therapist/ ethnicity of therapist?

Is there any other information you wish to provide?

Has funding been agreed for this therapy? *

How much can be contributed?*

Have all other potential funding sources been explored such as Pupil Premium via the school, health and social services, support from relatives and other charitable sources?*

Have referrals for this support been made to other services?*

Name of Service*

Outcome of Enquiry*

How did you hear about us?*

Detail*

Social Worker name & contact details*

Organisation name*

Child/Young Person Referral Form