YP Referral Form - Staff Stars

Section 1 - Referrer’s Details

The details of the professional who is referring someone to the service.

Contact Number(Required)

Email Address(Required)

Your Job Role(Required)

Your Organisation(Required)

Person to contact in your absence:(Required)

Section 2 - Client's Details

The details of the person who is being referred to the service.

Date of Birth(Required)

Age(Required)

Ethnicity(Required)

Preferred Language(Required)

Contact Number(Required)

Email Address(Required)

Parent/carer's name and contact number(Required)

Pronouns(Required)

Name of school or college

Name of employer

If you feel comfortable doing so, please detail your disabilities or learning needs

Details of the professional currently working with the client to support their mental health

Where would the young person like to be seen?(Required)

Please select a location from the dropdown menu

If yes, please record detail below

Who does the young person live with?(Required)

Section 3 - Referral Details

Please record information in as much detail as possible, as this helps the service to determine risk levels

Substances currently being used

Route (i.e. smoking, oral, snorting etc.)

How much? (Money, bags, cans, bottles, units etc.)

How often? (Daily, 24/7, weekly, binge etc.)

Is the young person aware of the substance use within the family?

What impact does the substance use have on the young person?

What substances are being used?

What contact does the young person have with the family member using substances?

Any details or risks we need be aware of in a group environment?

Section 4 - Safeguarding Concerns

Social worker's name and contact details

If applicable

Please detail reason for involvement or safeguarding concerns

Section 5 - Exploitation/CCE & CSE

Please attach the RFM

Max. file size: 20 MB.

Section 6 - Offending

Case Manager's name

Please detail offence type/s and any additional information

Section 7 - Strengths and Positive Factors for the Young Person

Please record what strengths the young person has and the protective factors in place for them(Required)

Section 8 - Additional Information

Please record any additional information such as safeguarding, risks to home visiting, risk to worker, exploitation, overdose, injecting, offending, physical/mental health issues, binge use and any other relevant information.

To refer a young person please see the online referral form below:

Young Person Online Referral Form

Young Person Referral Form