Belonging Service Nomination Form

Belonging Service Nomination Form

About the Belonging Service: The Anchor SCIO’s Belonging Service provides relationship-first, trauma-responsive support for young people and young adults aged 12–24 who are on the edges of society. This includes those experiencing suicide risk, emotional-based school avoidance, exclusion, exploitation, gender-based violence, or contact with the justice system. Our approach is built on the Social Ecological Model – recognising that a young person’s wellbeing is shaped not only by their own experiences but also by their family, community, and wider societal factors such as poverty, stigma, and inequality. This nomination form is designed to capture a full picture of the young person’s context, ensuring we can build a safe, tailored, and relational support plan in partnership with them and their families.
Today’s Date
Your Name and Job Title / Relationship to YP

NameJob Title
Your Email
Your Contact Number
Please enter a contact number
Young Person's Name

First NameLast Name
Young Person's Date of Birth
What age of service would they require?
Young Person's Home Address
Young Person's Post Code
Young Person's School / College (if appropriate)
Where are you nominating from? If your organisation is not on this list, please contact support@anchor-scio.co.uk for further advice.
Please tell us why you are referring this young person for support, and what you feel the most helpful next steps would be.
What concerns are present for the young person?
Is this a specific referral for the Autistic Adult Support Fund?
We will now require information to begin building a picture of the young person's wider picture to allow us to plan the best support possible for them. This will be through the lens of our social ecological model of support.
Individual: please tell us the young person's key strengths (interests, skills, motivators). Please tell us their main difficulties (mental health, coping, identity).
Family: please tell us about the wider family support system and the key family strengths. Also include any safeguarding concerns at home.
Community: how is engagement with education, what are the peer / friend situation like at home / online, what is the community involvement like in groups / sports / faith and what risks are posed in the community for the young person.
Society and wider factors: how is the young person and their family in terms of financial support, does the young person experience any discrimination in society, is there any statutory involvement in their life and is there any systemic barriers (CAMHS waiting lists, housing insecurity etc).
The next section will focus on risk information and any safety planning needs.
Has the young person previously experienced suicidal thoughts?
Are there immediate safety concerns for the young person or other people?
Is there a Safe Plan in place already?
Please provide an emergency contact relating to any safe plans (if appropriate)
Young Person's Responsible Adult

NameRelationship to Young Person
Young Person's Responsible Adult Phone Number
Has the young person consented to this nomination being placed on their behalf?
Has this nomination been discussed with the wider family / appropriate adults?
I understand that The Anchor will be in touch for the next steps relating to the young person's nomination to the service. This might include the offer of support, but this will be confirmed shortly. I also understand that if there is a wait for support, that The Anchor run Crisis Support every Monday and that the young person and any linked adults can pop in for a chat between 10am and 6pm.
This section is for internal use only.
This was form was received by the Hub Co-ordinator and processed internally
Date logged in the internal system (by Hub Co-ordinator)
Allocated Worker
Date practitioner was allocated (by Head of Ops)
Initial date contact was made with the family / young person (by practitioner)
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