Whole Family Support Referral Form

Whole Family Support 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 families, ensuring an effective match with appropriate COVEY 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.
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 Phone Number (no spaces)
Please enter a valid phone number.
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):*
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):
Parent/Carer 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
Parent/Carer 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
What are the issues affecting the Parent/Carer?*

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

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 or Employment Status:*

SchoolCollege or UniversityEmployedUnemployedVolunteeringNot in Employment, Education or Training
Parent/Carer's Education or Employment Status:*

College or UniversityEmployedUnemployedVolunteeringNot in Employment, Education or Training
Additional Support Needs and Self-Directed Support (SDS)
Does the family 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*

0/2000
Does the family 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*

0/2000
Is the family receiving an SDS Budget?*
If yes, please select the applicable SDS Budget Option.*

Direct paymentIndividual chooses servicesLocal authority managed
Additional comments on SDS use:

0/2000
Additional Information
Does the family have social work involvement?*
Please provide information on this social work involvement:*
Are other agencies involved in supporting the family? *
Please provide information on this involvement of other agencies:*

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

0/2000
Does the parent/carer have any medical conditions, allergies, or dietary requirements?*
Details about the parent/carer's 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 the child/young person's aggressive, violent and/or inappropriate behaviour towards others:*

0/2000
Has the parent/carer ever displayed aggressive, violent, or inappropriate behaviour towards others?*
Details about the parent/carer's 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
Does the parent/carer have any hobbies or interests?*
Details about the parent/carer's 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)*
Details about these other issues or needs:*
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 these issues and/or risks*
Consent and Declaration
Consent and Declaration*

I confirm that I have obtained consent from the family to submit this referral.
Should be Empty:

Whole Family Support Referral Form

Referrer Information

Child/Young Person's Personal Information

Family Details

Referral Information

Additional Support Needs and Self-Directed Support (SDS)

Additional Information

Consent and Declaration