Internal Referral Form: Whole Family Support

Internal Referral: Whole Family Support
Before completing this internal referral form, please make sure you've assessed the suitability of the referral with relevant team members, including Service Managers.

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.

There is an option at the bottom of this form to submit information about any new children/young people being introduced to COVEY as part of this internal referral. Up to 5 children/young people's details can be added. A new Salesforce record will automatically be created for each new child/young person added to this form.

Please take some time to review the form before filling it in to make sure you have all the required information.
Name of COVEY team member completing this referral:
Name

First NameLast Name
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 ProtectionDistressed BehavioursLow Self EsteemBereavementBullyingIllnessDisabilityMental HealthSubstance MisuseSingle Parent FamilyDomestic ViolenceOffendingAbuse (Mental, Physical, Sexual)Care ExperiencedSchool/Education IssuesYoung CarerUnsafe RelationshipsOther
Other issues affecting the child/young person:

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What are the issues affecting the Parent/Carer?*

Social IsolationChild ProtectionDistressed BehavioursLow Self EsteemBereavementBullyingIllnessDisabilityMental HealthSubstance MisuseSingle Parent FamilyDomestic ViolenceOffendingAbuse (Mental, Physical, Sexual)Care ExperiencedSchool/Education IssuesYoung CarerUnsafe RelationshipsOther
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:

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How Can COVEY Support the parent/carer? (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 the parent/carer:*

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How Can COVEY Support the child/young person? (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 the child/young person*

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 parent/carer have diagnosed Additional Support Needs?*
If yes, please specify the type of diagnosed support needs of the parent/carer, e.g. learning disability, physical disability, sensory impairment, autism spectrum disorder*

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Does the child/young person have diagnosed Additional Support Needs?*
If yes, please specify the type of diagnosed support needs of the child/young person e.g. learning disability, physical disability, sensory impairment, autism spectrum disorder*

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Does the parent/carer have undiagnosed Additional Support Needs?*
If yes, please specify the type of undiagnosed support needs of the parent/carer, e.g. learning disability, physical disability, sensory impairment, autism spectrum disorder*

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Does the child/young person have undiagnosed Additional Support Needs?*
If yes, please specify the type of undiagnosed support needs of the child/young person, e.g. learning disability, physical disability, sensory impairment, autism spectrum disorder*

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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 parent/carer have social work involvement?*
Please provide information on this social work involvement relating to the parent/carer:*
Does the child/young person have social work involvement?*
Please provide information on this social work involvement relating to the child/young person:*
Are other agencies involved in supporting the parent/carer *
Please provide information on this involvement of other agencies relating to the parent/carer:*

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Are other agencies involved in supporting the child/young person *
Please provide information on this involvement of other agencies relating to the child/young person:*

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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*
Are you referring any new children/young people to COVEY via this internal referral? i.e. children/young people that are not currently being supported by COVEY, but will be once this referral process is complete?

YesNo
Name of new COVEY participant:

First NameLast Name
New Child/Young Person Address*

Street Address

Street Address Line 2

CityLocal Authority

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

DayMonthYear
Date
New Child/Young Person's School/College/Other Educational Setting*
New Child/Young Person Gender*
Other new Child/Young Person Gender:
New Child/Young Person Landline Phone Number (no spaces)
Please enter a valid phone number.
New Child/Young Person Mobile Phone Number (no spaces)
Please enter a valid phone number.
New 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
New Child/Young Person Ethnicity (other):*
What are the issues affecting the new child/young person?*

Social IsolationChild ProtectionDistressed BehavioursLow Self EsteemBereavementBullyingIllnessDisabilityMental HealthSubstance MisuseSingle Parent FamilyDomestic ViolenceOffendingAbuse (Mental, Physical, Sexual)Care ExperiencedSchool/Education IssuesYoung CarerUnsafe RelationshipsOther
Other issues affecting the new child/young person:

0/2000
How Can COVEY Support the new child/young person? (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 the new child/young person:*

0/2000
New Child/Young Person Education or Employment Status:*

SchoolCollege or UniversityEmployedUnemployedVolunteeringNot in Employment, Education or Training
Is the new child/young person under a Supervision Order or on the Child Protection Register? *
Please provide information relating to Supervision Order or Child Protection Register for the new child/young person:*
Does the new child/young person have any medical conditions, allergies, or dietary requirements?*
Details about the new child/young person's medical conditions, allergies and/or dietary requirements:*

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

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

0/2000
Are you referring another new children/young people to COVEY via this internal referral? i.e. children/young people that are not currently being supported by COVEY, but will be once this referral process is complete?

YesNo
Name of new COVEY participant (2):

First NameLast Name
New Child/Young Person Address (2)*

Street Address

Street Address Line 2

CityLocal Authority

Postcode
New Child/Young Person Local Authority (2)*
New Child/Young Person Date of Birth (2)*

DayMonthYear
Date
New Child/Young Person's School/College/Other Educational Setting (2)*
New Child/Young Person Gender (2)*
Other new Child/Young Person Gender (2):
New Child/Young Person Landline Phone Number (no spaces) (2)
Please enter a valid phone number.
New Child/Young Person Mobile Phone Number (no spaces) (2)
Please enter a valid phone number.
New Child/Young Person Ethnicity (select which applies) (2)*

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) (2)*
What are the issues affecting the new child/young person? (2)*

Social IsolationChild ProtectionDistressed BehavioursLow Self EsteemBereavementBullyingIllnessDisabilityMental HealthSubstance MisuseSingle Parent FamilyDomestic ViolenceOffendingAbuse (Mental, Physical, Sexual)Care ExperiencedSchool/Education IssuesYoung CarerUnsafe RelationshipsOther
Other issues affecting the new child/young person: (2)

0/2000
How Can COVEY Support the new child/young person? (select all that apply) (2)*

Improve Health and WellbeingIncrease Confidence/Self EsteemBuild Stronger Connections and Reduce IsolationImprove Educational Attainment and Positive DestinationsOther
Other ways COVEY can support the new child/young person: (2)*

0/2000
New Child/Young Person Education or Employment Status: (2)*

SchoolCollege or UniversityEmployedUnemployedVolunteeringNot in Employment, Education or Training
Is the new child/young person under a Supervision Order or on the Child Protection Register? (2)*
Please provide information relating to Supervision Order or Child Protection Register for the new child/young person: (2)*
Does the new child/young person have any medical conditions, allergies, or dietary requirements? (2)*
Details about the new child/young person's medical conditions, allergies and/or dietary requirements: (2)*

0/2000
Has the new child/young person ever displayed aggressive, violent, or inappropriate behaviour towards others? (2)*
Details about the new child/young person's aggressive, violent and/or inappropriate behaviour towards others: (2)*

0/2000
Does the new child/young person have any hobbies or interests? (2)*
Details about new child/young person hobbies and/or interests: (2)*

0/2000
Are you referring another new children/young people to COVEY via this internal referral? i.e. children/young people that are not currently being supported by COVEY, but will be once this referral process is complete?

YesNo
Name of new COVEY participant (3):

First NameLast Name
New Child/Young Person Address (3)*

Street Address

Street Address Line 2

CityLocal Authority

Postcode
New Child/Young Person Local Authority (3)*
New Child/Young Person Date of Birth (3)*

DayMonthYear
Date
New Child/Young Person's School/College/Other Educational Setting (3)*
New Child/Young Person Gender (3)*
Other new Child/Young Person Gender (3):
New Child/Young Person Landline Phone Number (no spaces) (3)
Please enter a valid phone number.
New Child/Young Person Mobile Phone Number (no spaces) (3)
Please enter a valid phone number.
New Child/Young Person Ethnicity (select which applies) (3)*

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) (3)*
What are the issues affecting the new child/young person? (3)*

Social IsolationChild ProtectionDistressed BehavioursLow Self EsteemBereavementBullyingIllnessDisabilityMental HealthSubstance MisuseSingle Parent FamilyDomestic ViolenceOffendingAbuse (Mental, Physical, Sexual)Care ExperiencedSchool/Education IssuesYoung CarerUnsafe RelationshipsOther
Other issues affecting the new child/young person: (3)

0/2000
How Can COVEY Support the new child/young person? (select all that apply) (3)*

Improve Health and WellbeingIncrease Confidence/Self EsteemBuild Stronger Connections and Reduce IsolationImprove Educational Attainment and Positive DestinationsOther
Other ways COVEY can support the new child/young person: (3)*

0/2000
New Child/Young Person Education or Employment Status: (3)*

SchoolCollege or UniversityEmployedUnemployedVolunteeringNot in Employment, Education or Training
Is the new child/young person under a Supervision Order or on the Child Protection Register? (3)*
Please provide information relating to Supervision Order or Child Protection Register for the new child/young person: (3)*
Does the new child/young person have any medical conditions, allergies, or dietary requirements? (3)*
Details about the new child/young person's medical conditions, allergies and/or dietary requirements: (3)*

0/2000
Has the new child/young person ever displayed aggressive, violent, or inappropriate behaviour towards others? (3)*
Details about the new child/young person's aggressive, violent and/or inappropriate behaviour towards others: (3)*

0/2000
Does the new child/young person have any hobbies or interests? (3)*
Details about new child/young person hobbies and/or interests: (3)*

0/2000
Are you referring another new children/young people to COVEY via this internal referral? i.e. children/young people that are not currently being supported by COVEY, but will be once this referral process is complete?

YesNo
Name of new COVEY participant (4):

First NameLast Name
New Child/Young Person Address (4)*

Street Address

Street Address Line 2

CityLocal Authority

Postcode
New Child/Young Person Local Authority (4)*
New Child/Young Person Date of Birth (4)*

DayMonthYear
Date
New Child/Young Person's School/College/Other Educational Setting (4)*
New Child/Young Person Gender (4)*
Other new Child/Young Person Gender (4):
New Child/Young Person Landline Phone Number (no spaces) (4)
Please enter a valid phone number.
New Child/Young Person Mobile Phone Number (no spaces) (4)
Please enter a valid phone number.
New Child/Young Person Ethnicity (select which applies) (4)*

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) (4)*
What are the issues affecting the new child/young person? (4)*

Social IsolationChild ProtectionDistressed BehavioursLow Self EsteemBereavementBullyingIllnessDisabilityMental HealthSubstance MisuseSingle Parent FamilyDomestic ViolenceOffendingAbuse (Mental, Physical, Sexual)Care ExperiencedSchool/Education IssuesYoung CarerUnsafe RelationshipsOther
Other issues affecting the new child/young person: (4)

0/2000
How Can COVEY Support the new child/young person? (select all that apply) (4)*

Improve Health and WellbeingIncrease Confidence/Self EsteemBuild Stronger Connections and Reduce IsolationImprove Educational Attainment and Positive DestinationsOther
Other ways COVEY can support the new child/young person: (4)*

0/2000
New Child/Young Person Education or Employment Status: (4)*

SchoolCollege or UniversityEmployedUnemployedVolunteeringNot in Employment, Education or Training
Is the new child/young person under a Supervision Order or on the Child Protection Register? (4)*
Please provide information relating to Supervision Order or Child Protection Register for the new child/young person: (4)*
Does the new child/young person have any medical conditions, allergies, or dietary requirements? (4)*
Details about the new child/young person's medical conditions, allergies and/or dietary requirements: (4)*

0/2000
Has the new child/young person ever displayed aggressive, violent, or inappropriate behaviour towards others? (4)*
Details about the new child/young person's aggressive, violent and/or inappropriate behaviour towards others: (4)*

0/2000
Does the new child/young person have any hobbies or interests? (4)*
Details about new child/young person hobbies and/or interests: (4)*

0/2000
Are you referring another new children/young people to COVEY via this internal referral? i.e. children/young people that are not currently being supported by COVEY, but will be once this referral process is complete?

YesNo
Name of new COVEY participant (5):

First NameLast Name
New Child/Young Person Address (5)*

Street Address

Street Address Line 2

CityLocal Authority

Postcode
New Child/Young Person Local Authority (5)*
New Child/Young Person Date of Birth (5)*

DayMonthYear
Date
New Child/Young Person's School/College/Other Educational Setting (5)*
New Child/Young Person Gender (5)*
Other new Child/Young Person Gender (5):
New Child/Young Person Landline Phone Number (no spaces) (5)
Please enter a valid phone number.
New Child/Young Person Mobile Phone Number (no spaces) (5)
Please enter a valid phone number.
New Child/Young Person Ethnicity (select which applies) (5)*

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) (5)*
What are the issues affecting the new child/young person? (5)*

Social IsolationChild ProtectionDistressed BehavioursLow Self EsteemBereavementBullyingIllnessDisabilityMental HealthSubstance MisuseSingle Parent FamilyDomestic ViolenceOffendingAbuse (Mental, Physical, Sexual)Care ExperiencedSchool/Education IssuesYoung CarerUnsafe RelationshipsOther
Other issues affecting the new child/young person: (5)

0/2000
How Can COVEY Support the new child/young person? (select all that apply) (5)*

Improve Health and WellbeingIncrease Confidence/Self EsteemBuild Stronger Connections and Reduce IsolationImprove Educational Attainment and Positive DestinationsOther
Other ways COVEY can support the new child/young person: (5)*

0/2000
New Child/Young Person Education or Employment Status: (5)*

SchoolCollege or UniversityEmployedUnemployedVolunteeringNot in Employment, Education or Training
Is the new child/young person under a Supervision Order or on the Child Protection Register? (5)*
Please provide information relating to Supervision Order or Child Protection Register for the new child/young person: (5)*
Does the new child/young person have any medical conditions, allergies, or dietary requirements? (5)*
Details about the new child/young person's medical conditions, allergies and/or dietary requirements: (5)*

0/2000
Has the new child/young person ever displayed aggressive, violent, or inappropriate behaviour towards others? (5)*
Details about the new child/young person's aggressive, violent and/or inappropriate behaviour towards others: (5)*

0/2000
Does the new child/young person have any hobbies or interests? (5)*
Details about new child/young person hobbies and/or interests: (5)*

0/2000
Consent and Declaration
Consent and Declaration*

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

Internal Referral: Whole Family Support

Name of COVEY team member completing this referral:

Child/Young Person's Personal Information

Family Details

Referral Information

Additional Support Needs and Self-Directed Support (SDS)

Additional Information

Consent and Declaration