Referrers contact number * Referrers email * Date of referral * Team (if applicable) Referral being made as an outcome from referral into Early Help Hub * Young person being referred details * Preferred pronouns (he/she/they/them etc.) * Address * Postcode * County * Flintshire Date of birth * Young person's health conditions/specific needs that need to be considered If other, please specify language and whether an interpreter is required Any religious / cultural issues to take into consideration Young person's contact number Young person's email address Name of education placement (school/college/home schooled/NEET) By referring this young person, you are confirming you have spoken to the family, shared information about the service and have gained consent to pass personal details to NEWCIS and for NEWCIS to hold those personal details on our secure system * By referring this young person, you are confirming you have spoken to the family, shared information about the service and have gained consent to pass personal details to NEWCIS and for NEWCIS to hold those personal details on our secure system * How/where did you hear about us? Please be specific (E.g. Leaflet, social media, school, online search, professional/other service) Reason for referral - What is the intended outcome? What is it that you hope we can help the young person with? * Please provide information about the caring role - Who is the young person supporting and what are they doing to help them? i.e., practical tasks, emotional support, etc. * What is the impact of the caring role on the young person - In what ways is this affecting them, for example limited time with friends or time away from caring role/poor mental health/increased isolation etc. * Are there any other services involved with young person and family? Please indicate services and which family member they are supporting. * Parent/guardian details - name * Parent/guardian date of birth If other, please specify language and whether an interpreter is required Parent/guardian contact number * Parent/guardian email * Preferred contact method for young person/family *
For an initial information pack, essential forms, and future correspondence.
Please include any details that are important for us to be aware of (E.g., Child protection issues & status/safeguarding, sensitive cultural/personal circumstances etc.) Cared for details - Name and relationship to the young person? * Cared for date of birth * Cared for's health conditions and needs * Please provide information regarding any further caring roles the young person has within in the family * ACEs check list (current or historical) Are there any identified risks? Please specify who/what the risk(s) are. If a risk is identified, details of risk must be provided, or referral will not be taken.
For example, environmental risk - access to property, hazards in or around property. Risk to self - safeguarding issues, self-harm, substance misuse. Risk to others - history of verbal or physical aggression, pets at the property.