CYP Referrals

If you would like to make a CYP referral for our services please find our referral form below, or you can contact us by phone on: 01933 227 078.

We aim to contact you within 5 working days.

If you are referring from an agency we will contact you to confirm receipt.

    Date of Birth

    Address




    Has the child/young person consented to this referral?

    YesNo

    Has the parent/guardian consented to this referral?

    YesNo

    Parent/Guardian details

    Do we have permission to contact the parent/guardian using the details above?

    YesNo

    Do we have permission to leave a message on their phone?

    YesNo

    Young Person details

    Do we have permission from the young person to contact them using the details above?

    YesNo

    Do we have permission to leave a message on their phone?

    YesNo

    Do we have permission to leave a message on their phone?

    YesNo

    Is the CYP enrolled in an Education setting (eg: school, college, alternative provision)

    YesNo

    Is the CYP currently excluded from school?

    YesNo

    Is the CYP Home educated?

    YesNo

    Does the CYP have an EHCP?

    YesNoDon't Know

    Does the CYP have any additional needs (eg: learning differences, mental health, disabilities)

    YesNo

    Does the CYP qualify for Pupil Premium support?

    YesNoDon't Know

    Is the CYP involved in any of the following:
    Early Help Assessment (EHA)

    YesNoDon't Know

    Child In Need Plan (CIN)

    YesNoDon't Know

    Child Protection Plan (CPP)

    YesNoDon't Know

    Looked After Child – Kin Care (LAC)

    YesNoDon't Know

    Looked After Child – Foster care (LAC)

    YesNoDon't Know

    Is there any known current DV/DA

    YesNoDon't Know

    Is the CYP involved with the Police/Youth Courts/Risky behaviours

    YesNoDon't Know

    Is this CYP a carer for a member of their family?

    YesNoDon't Know

    Referred by:

    SelfProfessional

    Professional Details


    If referred by a professional please give address and contact details below:

    Address Details




    Contact Details

    Substances involved:

    DrugsPrescription drugsAlcohol

    Are there any other professionals involved?

    YesNoDon't know

    Consent:


    By ticking this box, you confirm that you give consent or in the case of a third party referrer, have gained consent for us to store this data on the Northamptonshire Treatment System.

    YesNo

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