Young person's details

Required
Required
Required

Young person's contact details

Required
Preferred contact method Required
Has the young person given consent for contact? Required
In line with the GDPR please confirm that you have discussed the referral with the young person and they have agreed to it being made Required
Are their parents/carers aware of this referral? (they don’t necessarily need to be) Required
Required
Please tick any substances currently used Required
Required
Please tick any substances previously used Required
Required

Referrer details

Required
Required
Required
Required
Required
Required
Required

Risk assessment

Is the young person a risk to them self? Required
Required
Is the young person a risk to others? Required
Required
Is the young person at risk from others? Required
Required
Required

Other risk factors – please answer each of these as it can help us prioritise referrals

Offending behaviour Required
LAC/OLAC Required
Safeguarding issues/Child In Need/CP Required
Excluded/truancy/NEET/poor school attendance Required
Unstable accommodation Required
Risky sexual activity Required
At risk of CSE Required
Learning disability/cognitive issues Required
Mental health/wellbeing issues Required
Family substance use issues Required
Repeated injuries or A&E attendance Required
Pregnant or partner pregnant Required
Dependent children Required
Poly drug use (mixing substances) Required