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REFERRAL OF A YOUNG PERSON Note: This form MUST be completed in full. All sections are mandatory. INFORMATION ABOUT THE REFERRER Name and status of named referrer Organisation Authorised telephone number/s Authorised email address/es INFORMATION ABOUT THE YOUNG PERSON & CARER Young person Date of birth Address Telephone numbers Is the child eligible for FSM? Parent/Carers – Key contact Parent/ Carers email (for remote learning purposes) Is parent/carer aware of the service/ referral? Is the parent/carer digitally literate? Any other known challenges? CF EDUCATION Offering unconditional positive regard to children, young people and families V1
Transcript of ipswichoa.files.wordpress.com · Web view2021. 2. 25. · For any YES response up to date...
REFERRAL OF A YOUNG PERSON
Note: This form MUST be completed in full. All sections are mandatory.INFORMATION ABOUT THE REFERRER
Name and status of named referrer
OrganisationAuthorised telephone number/s
Authorised email address/es
INFORMATION ABOUT THE YOUNG PERSON & CARERYoung personDate of birth
AddressTelephone numbers
Is the child eligible for FSM?Parent/Carers – Key contact
Parent/ Carers email (for remote learning purposes)
Is parent/carer aware of the service/ referral?
Is the parent/carer digitally literate? Any other known
challenges?
CF EDUCATIONOffering unconditional positive regard to children, young
people and families
V1
INFORMATION ABOUT THE YOUNG PERSON’S PROFILE AND NEEDSFor any YES response up to date additional details MUST be attached to this referral
Please circle/ underline a response: YES or NO Is the young person subject to any form of physical / medical care plan? YES NOIs the young person subject to any form of mental health care plan? YES NOIs the young person associated with current or previous legal actions / provisions?
YES NO
Is the young person associated with current or previous safeguarding concerns? YES NOIs the young person subject to any form of risk assessment YES NOKnown challenges with home learningEngagement during last lockdown NONE LIIMITED MODERATE GOOD EXCELLENT
REQUIRED SUPPORTPlease detail:
Areas of concern?How can we help?Outcomes?
Page 1 of 2SUPPORT REQUIRED
Packages are a guide and we are able to provide bespoke packages upon request
Package Package 1 Set up phone call: introduction to the service, how we can help. 2 weekly phone calls (probs Mon & Weds) Total support: 9 phone calls
Package 2 Set up phone call: introduction to the service, how we can help. 3 weekly phone calls (Mon, Weds & Fri)Total support: 13 calls
Package 3
Set up phone call: introduction to the service, how we can help. 2 weekly phone calls and 1 face-to-face (virtual if required) session in the home.Total support: 9 calls and 4 face-to-face sessions
Package 4 Set up phone call: introduction to the service, how we can help. 2 face-to-face sessions (virtual if required) in the home and 1 call.Total support: 5 calls and 8 face-to-face sessions
Package 5 Set up phone call: introduction to the service, how we can help. 2 face-to-face sessions (virtual if required) in the home and 3 calls.Total support: 13 calls and 8 face-to-face
Please email this referral (and any attachments) to: [email protected] Or post it to: CF (Education), Delta 1, West Road, Ipswich. IP3 9FH
We put the needs of children, young people and their families and carers at the heart of everything we do.
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