Befriending/Mentoring Referral Form

Child/Young Person Referral Form
The COVEY referral process involves the referrer completing the referral form (see below), which may be further filled out by a COVEY representative if necessary. This form is designed to identify the specific needs of children and young people, ensuring an effective match with appropriate Befriending/ Mentoring services.

This form must be completed in a single sitting, as your progress cannot be saved and revisited. As the referrer, you must have consent from the Parent/Carer and/or Young Person to make this referral.

Please take some time to review the form before filling it in to make sure you have all the required information.
Project Information
Which COVEY Project do you feel best applies to the person you are referring?

Please note that our team will work together to consider suitability across all projects. However, providing this information will help our referral process.
Project

Building Brighter FuturesANGELS (Additional Needs Gaining Experience in Life Skills)North Lanarkshire BefriendingIntandemCOVEY ConnectUnsure
Referrer Information
Referrer First Name*
Referrer Last Name*
Referrer Job Title*
Referring Organisation*
Referrer Email*
example@example.com
Referrer Phone Number (no spaces)*
Please enter a valid phone number.
Child/Young Person's Personal Information
Child/Young Person First Name*
Child/Young Person Last Name*
Child/Young Person Address*

Street Address

Street Address Line 2

CityLocal Authority

Postcode
Child/Young Person Local Authority*
Child/Young Person Date of Birth*

DayMonthYear
Date
School/College/Other Educational Setting*
Child/Young Person Gender*
Other Child/Young Person Gender:*
Child/Young Person Landline Phone Number (no spaces)
Please enter a valid phone number.
Child/Young Person Mobile Number (no spaces)
Please enter a valid phone number.
Family Details
Parent/Carer First Name*
Parent/Carer Last Name*
Parent/Carer Address*

Street Address

Street Address Line 2

CityLocal Authority

Postcode
Parent/Carer Local Authority*
Parent/Carer Date of Birth*

DayMonthYear
Date
Parent/Carer Email
example@example.com
Parent/Carer Landline Phone Number (no spaces)
Please enter a valid phone number.
Parent/Carer Mobile Phone Number (no spaces)*
Please enter a valid phone number.
Relationship to Child/Young Person*
Relationship to Child/Young Person (other):*
Does Child/Young Person have a sibling or siblings?*
Names and ages of Child/Young Person's sibling(s):*

0/1000
Child/Young Person Ethnicity (select which applies)*

Prefer not to sayWhite BritishWhite IrishAsian BritishAsian/Indian or Asian British/IndianAsian/Pakistani or Asian British/PakistaniAsian/Bangladeshi or Asian British/BangladeshiAsian/Chinese or Asian British/ChineseAsian or Asian British/Other (please specify below)Black/Black BritishBlack/African or Black British/AfricanBlack/Caribbean or Black British/CaribbeanWhite and Black CaribbeanWhite and Black AfricanWhite and AsianArabUnknownOther
Child/Young Person Ethnicity (other):*
Referral Information
What are the issues affecting the child/young person?*

Social IsolationChild ProtectionBehavioural ProblemsLow Self EsteemBereavementBullyingIllnessDisabilityMental HealthSubstance MisuseSingle Parent FamilyDomestic ViolenceOffendingAbuse (Mental, Physical, Sexual)Care ExperiencedSchool/Education IssuesYoung CarerInappropriate FriendshipsOther
Other issues affecting the child/young person:*

0/2000
The Scottish Government has identified the following six types of families most at risk of poverty, forming the focus of their child poverty reduction strategies. COVEY is working alongside that strategy, providing services.
Please select which family type(s) apply:*

Lone Parent FamilyMinority Ethnic FamilyFamily with Disabled Adult or ChildFamily with Mother aged 25 and UnderFamily with a Child Under OneLarger Family (three or more children)None of the above
Additional information for each 'family type' selected in the above question:*

0/2000
How Can COVEY Support? (select all that apply)*

Improve Health and WellbeingIncrease Confidence/Self EsteemBuild Stronger Connections and Reduce IsolationImprove Educational Attainment and Positive DestinationsOther
Other ways COVEY can support:*

0/2000
Child/Young Person Education/Employment Status
Current Status (select all that apply)*

SchoolCollege or UniversityEmployedUnemployedVolunteeringNot in Employment, Education or Training
Additional Support Needs and Self-Directed Support (SDS)
Does child/young Person have diagnosed additional support needs?*
If yes, please specify the type of diagnosed support needs, e.g. learning disability, physical disability, sensory impairment, autism spectrum disorder*
Does child/young Person have undiagnosed additional support needs?*
If yes, please specify the type of undiagnosed support needs, e.g. learning disability, physical disability, sensory impairment, autism spectrum disorder*
Is the Child/Young Person receiving an SDS Budget?*
If yes, please select the applicable SDS Budget Option.*

Direct paymentIndividual chooses servicesLocal authority managed
Additional comments on SDS use:
Additional Information
Does the child/young person have social work involvement?*
Please provide information on child/young person social work involvement:*

0/2000
Does the child/young person have other agencies involved? *
Please provide information on child/young person other agency involvement:*

0/2000
Is the child/young person under a Supervision Order or on the Child Protection Register? *
Please provide information relating to Supervision Order or Child Protection Register:*

0/2000
Does the child/young person have any medical conditions, allergies, or dietary requirements?*
Details about medical conditions, allergies and/or dietary requirements:*

0/2000
Has the child/young person ever displayed aggressive, violent, or inappropriate behaviour towards others?*
Details about aggressive, violent and/or inappropriate behaviour towards others:*

0/2000
Does the child/young person have any hobbies or interests?*
Details about child/young person hobbies and/or interests:*

0/2000
Are there any issues or needs affecting the young people and parent/carer that we should be aware of before we contact or visit? (e.g. visual/hearing impairment, history of violence/aggression, language barrier and/or known triggers)*
Details about parent/carer issues or needs:*

0/2000
A member of our team may make a solo visit to the home of the child/young person. Do you anticipate any issues and/or risks relating to this that we should consider?*
Details about possible issues/risks relating to a solo home visit:*
Consent and Declaration
Consent and Declaration*

I confirm that I have obtained consent from the Parent/Carer and/or Child/Young Person to submit this referral.
Should be Empty:

Child/Young Person Referral Form

Project Information

Referrer Information

Child/Young Person's Personal Information

Family Details

Referral Information

Child/Young Person Education/Employment Status

Additional Support Needs and Self-Directed Support (SDS)

Additional Information

Consent and Declaration