Internal Referral Form: Child/Young Person

Internal Referral: Child/Young Person
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
Referral Information
What are the issues affecting the child/young person?
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:
Additional information for each 'family type' selected in the above question:

0/2000
How Can COVEY Support? (select all that apply)
Other ways COVEY can support:

0/2000
Child/Young Person Education or Employment Status:
Additional Support Needs and Self-Directed Support (SDS)
Does the 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

0/2000
Does the 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

0/2000
Is the family receiving an SDS Budget?
If yes, please select the applicable SDS Budget Option.
Additional comments on SDS use:

0/2000
Additional Information
Does the child/young person have social work involvement?
Please provide information on this social work involvement:
Are other agencies involved in supporting the child/young person?
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
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
Does the child/young person have any hobbies or interests?
Details about child/young person hobbies and/or interests:

0/2000
Consent and Declaration
Consent and Declaration
Should be Empty:

Internal Referral: Child/Young Person

Name of COVEY team member completing this referral:

Child/Young Person's Personal Information

Referral Information

Additional Support Needs and Self-Directed Support (SDS)

Additional Information

Consent and Declaration