Test Form

TLC Referral Form (v2)

Are you professional referring someone?(Required)

Yes

Professional Referrals

Please ensure you read any relevant service criteria before completing this form.

Professionals: What service are you referring to?(Required)

Services

What service are you referring to?(Required)

Young Person's Location

Please enter information about the young person you are booking below.

Local Authority the Young Person lives in:(Required)

Housing Services

Housing Provider:(Required)

What best describes the client:(Required)

Jigsaw area you are referring from?(Required)

What Jigsaw Housing Team are you referring from?(Required)

Salford Referral

Please note that we do not accept Domestic Abuse Referrals or Counselling Self-Referrals for Young People in Salford. Referrals are to be submitted here: www.salfordfoundation.org.uk/sisprofessionals

Referrer Details

Please enter your details below so we can contact you about this if necessary

Referrer Name:(Required)

First Last

Name of Organisation:(Required)

Your Phone Number:(Required)

Your Email:(Required)

Young Person's Details

Young Person's Name:(Required)

First Last

Young Person's Gender:(Required)

Young Person's Date of Birth:(Required)

Young Person's Address:(Required)

Street Address Town / City Post Code

Is English the Person's first language:(Required)

Does the Young Person have any access or communication difficulties we need to be aware of? If so please describe:

Please describe what the young person requires support with and any other information you feel is relevant (including risk and safeguarding information):(Required)

Has the young person been made aware of this referral:(Required)

Partnered Schools

School/College the pupil attends:(Required)

Education details:(Required)

Listed at a school / college

Home-schooled

NEET (Not in employment, education or training)

School/ College address:(Required)

Please use the full school name and address.

School Name Address Borough / City Post Code

Background Information

We use this information to triage the young person to the most suitable support service.

Is the young person a Looked After Child?(Required)

Yes

Unsure

GP of the child / young person, if known:

Please describe what services are already provided to the child or family:

Details of any education healthcare plan:

Details of presenting problem:

Please give details about observed behaviours such as mood, emotions, communication, appetite, and sleep.

How long has this difficulty been present?

Is this difficulty present in all areas?

e.g. home, school and social settings

Social History:

Please include details of any relevant family circumstance, life events, bereavement, domestic abuse, parental mental health, learning needs or disability, ill health

Any known risk factors to the child and family:

e.g. violence, substance misuse

Please describe how you believe this referral will benefit this child or young person and what do you believe would be the most appropriate focus of our work?(Required)

What would the child or young person want us to work on with them?

Your Details

Please enter your information below to make a booking

Your Name:(Required)

First Last

Your Gender:(Required)

Your Date of Birth:(Required)

Your Address:(Required)

Street Address Address Line 2 City Post Code

Local Authority you live in:(Required)

Your Phone Number:(Required)

Your Email:(Required)

Please briefly describe what you require support with and any other information you feel is relevant:(Required)

Are you able to access TLC services Online?(Required)

Yes

Person's Details

Please enter information about the person you are referring below.

Person's Name:(Required)

First Last

Address:(Required)

Street Address Address Line 2 City Post Code

Person's Email:

Person's phone number:(Required)

Person's Date of Birth:(Required)

Person's Gender:(Required)

Is English the Person's first language:(Required)

Local Authority the Person lives in:(Required)

Has the Person consented to the referral:(Required)

Is it safe to leave a message for this Person:(Required)

What is the Person's preferred method of contact:(Required)

Phone Call

Text

Does the Person have any access or communication difficulties we need to be aware of? If so please describe:(Required)

Please describe what the person requires support with (including any including any relevant safeguarding and risk information):(Required)

Contact Safety

Is it safe to contact/leave a message?(Required)

Safe to send Text Messages

Safe to Leave Voice Mails

Not safe to leave messages

Domestic Abuse Service

This Information is for domestic abuse referral. For Perpetrator programs. There must be an acceptance of their actions/abuse. There must be a willingness to change.

Does the Person understand what the programme is about:(Required)

Are they living with their perpetrator or victim:(Required)

Is the Person at risk of being harmed or present a risk of harming others? Please provide details:(Required)

Is there an ongoing investigation for domestic abuse Is the person currently on bail for a domestic abuse offence(Required)

Are there any pending court dates for this offence(Required)

Is the person a risk to professionals?(Required)

Additional information

Is the Person involved in any of the following: (tick to answer yes)(Required)

Please describe what is in place for the client(Required)

Achieve Recovery Fund Referral Information

Referring Team(Required)

What is the person's history with substance misuse? (please include whether this is current or historic and if that are accessing other support)(Required)

Service delivery information

This information is required for a referral. Please note in-person may not always be available.

Preferred method of service delivery:(Required)

Online Video Call

Phone

In Person

One Manchester

Referring Team:(Required)

Right Angle

What school is the pupil enrolled at?(Required)

Pupil Year:(Required)

Pupil Premium Status:(Required)

Please select which tuition the pupil would like to receive - Maths or English:(Required)

English

Maths

Pupils are eligible for 12 hours of tuition in either English or Maths

Other Party Information

In order to process this referral, we will need additional details to ensure we can work in a safe way with all those involved. If you're referring an adult, please provide information on the former/current partner. If you're referring a child, please provide information on the child's parent/guardian.

Is the Other Party Aware of the Referral?(Required)

Yes

Who is the additional party:(Required)

Other Party Name:(Required)

First Last

Other Party Address:(Required)

Street Address Address Line 2 City Post Code

Other Party Date of Birth:(Required)

Other Party's Gender:(Required)

Other Party Email:

Other Party Phone Number:(Required)

Are there any other contact details we need to be aware of? (i.e. any additional agencies)(Required)

This can include school or social worker contact details

Mediation

Are there any orders in place preventing you from direct contact with the other party?(Required)

Yes

Funding:(Required)

Why does the person require Mediation:(Required)

Children

Property and Financial matters

Both

Other

Untitled

Schools Emotional Wellbeing Services

Are you referring in an Adult or Young Person?(Required)