Internal Referral: Child/Young Person Referral Form

Internal Referral Form: Child/Young Person
Is this child/young person currently being supported by COVEY in a different project?
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
Who is making this referral?
Your First Name
Your Last 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
2 digit day, 2 digit month, 4 digit yearDate
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.Format: 00000000000.
Child/Young Person Mobile Number (no spaces)
Please enter a valid phone number.Format: 00000000000.
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
2 digit day, 2 digit month, 4 digit yearDate
Parent/Carer Email
example@example.com
Parent/Carer Landline Phone Number (no spaces)
Please enter a valid phone number.Format: 00000000000.
Parent/Carer Mobile Phone Number (no spaces)
Please enter a valid phone number.Format: 00000000000.
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)
Child/Young Person Ethnicity (other):
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/Employment Status
Current Status (select all that apply)
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.
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:
Does the young person have any legal orders, restrictions or conditions placed upon them which could affect their ability to participate with this programme? e.g. Restriction of Liberty Order, Curfew, etc.
Does the young person have any previous charges or convictions? If so, please provide details on these:
Does the young person have any outstanding charges for which they are awaiting an outcome? If so, please provide details on these:
Consent and Declaration
Consent and Declaration
Should be Empty:

Internal Referral Form: Child/Young Person

Project Information

Who is making this referral?

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