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 referring 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

Important Update

Please note we are no longer accepting self-funded counselling enquiries. But these will be available soon through our subsidiary Now You're Talking, launching April 1st. Register interest here: www.nowyouretalkingtherapy.co.uk

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)

If council please specify department and Children/Adults

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 referral

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:

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

Cautioning and Relationship Abuse Service (CARA)

In this section you will provide specific information for this service. Note that victims should be consulted and aware of the referrals as they will be contacted as part of the program.

Date of Caution

Crime Reference Number(Required)

Type of Offence

Details of Offence

Type of Delivery Agreed

If CTI, please provide reason

Please provide any details around risk to self

Please provide any details around risk to others

Please provide any details around risk from others

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)

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. Domestic abuse perpetrator referrals please add victim details here. Family Mediation please add ex partner details here.

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 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

Why does the person require Mediation:(Required)

Children

Property and Financial matters

Both

Other

Further Information

Sex Therapy Attendee Information

Are you attending as an individual?(Required)

Yes

No, with partner/s

Is your partner/s aware of this referral, and consent to being contacted?(Required)

Yes

Schools Emotional Wellbeing Services

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

Counselling: Employer Partner

Which partner company are you from?(Required)

Recovery Counselling Referral Information

What is the person's history with alcohol or substance use? (please include whether this is current or historic and what additional support they are accessing). Please note counselling is not suitable for people who are currently in active addiction.(Required)

Please provide some additional information about your history with alcohol or substance use. (include whether this is current or historic and what additional support you are accessing). Please note counselling is not suitable for people who are currently in active addiction.(Required)

Education Gender Based Violence Information

School(Required)

Young Persons Name(Required)

Young Persons School Year(Required)

Referrer's Name(Required)

Referrers Job Title(Required)

Has there been a pattern of behaviour (recorded incidents) in relation to using inappropriate language including homophobic, sexist and other derogatory terms?(Required)

Additional Information

Is there any recorded incidents in relation to inappropriate sexualised behaviour and/or language which is not already being worked with by an external organisation? (Where there is external involvement already, we may not include YP in our intervention group)(Required)

Additional Information

Has the young person expressed views about other genders using negative language despite interventions by school? This may be with peers or in a classroom situation.(Required)

Additional Information

Does the young person take accountability for using harmful language/displaying harmful behaviours towards others? This may not be related to a specific learning need.(Required)

Additional Information

Has there been any idealisation of unhealthy role models which has been expressed in a number of environments with peers and/or in a classroom situation?(Required)

Additional Information

Do they express views about themselves in negative terms?(Required)

Additional Information

Does the young person find it difficult working alongside their peers and/or tend to try and control situations and friendships?(Required)

Additional Information