Referral Form: adding a child/young person to an existing referral

Referral Form: adding a child/young person to existing referral
This form should be used when adding an additional child/young person to an existing whole family support referral (e.g. a sibling has been identified as suitable for support who wasn't included in the original referral for the family.

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.
Name of COVEY team member making 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*
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:

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
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
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
Are there any issues or needs affecting the child/young person 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:*
Consent and Declaration
Consent and Declaration*

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

Referral Form: adding a child/young person to existing referral

Name of COVEY team member making 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