Targeted Intervention - Make a referral

Who is making the referral?:
I am a professional referring a Young PersonI am referring my child / a child in my careI am referring myself

Young Person’s details

This section will help us gather all the information we need to support the Young Person.

If you are a referring yourself please note that from this point on any question that asks about ‘Young Person’ is about yourself.

Young Person’s first name:

Young Person’s surname:

Young Person’s Email Address:

Young Person’s phone number:
If the young person is happy to be contacted by us directly about the referral, please include their number here.

Young Person’s post code:

Young Person’s gender:
FemaleMaleNon-BinaryOtherPrefer Not to Say

Young Person’s date of birth (DD/MM/YYYY):

Young Person’s ethnicity:
***Asian***BangladeshiChineseIndianPakistaniOther Asian***Black, Black British, Caribbean or African***AfricanCaribbeanOther Black***Mixed or Multiple ethnic groups***White and AsianWhite and Black AfricanWhite and Black CaribbeanOther Mixed or Multiple ethnic groups***White***IrishGypsy or Irish TravelerRomaOther White***Other ethnic group***ArabAny other ethnic group

Young Person’s nationality:

Do they have an SEND diagnosis or an EHCP?:
If YES, please use the further information box at the end of the form to share details.
YesNoUnsure

Education, Training, or Employment?:
Please select all that apply.

Are there any other professionals or agencies working with the Young Person?

Please select all that apply.

Please ensure that if there are other professionals/organisations involved with the young person or family, that they have been made aware of the referral.

Other professionals or agencies?:
Please select all that apply.

Young Person any of the following?:
CLA (Child looked after)Care LeaverNot applicable

Parent / guardian / emergency contact details

If N/A due to being over 18, please note that we will still require an emergency contact.

Parent/guardian first name:

Parent/guardian surname:

Parent/guardian contact number:
Please include the details of the responsible adult we can contact about the referral.

Parent/guardian email address:

Relationship to Young Person:
CAMHS WorkerCarerFoster ParentGrandparentGuardianMentorParentPastoral Support (School)SiblingSocial WorkerSupport WorkerYouth Justice Worker

Context for the referral

This section will help us understand the reason(s) you have made a referral to access the Palace for Life Foundation’s Targeted Intervention service. Please be as open and honest as possible.

Reason to make a referral?:
Please select all that apply.

What are your current concerns for the Young Person?:
Please outline current concerns and impact. For example, relating to home life, mental health and wellbeing, peer group etc.

What is going well for the Young Person?:
Please include any interests and hobbies the Young Person has, and describe their protective factors (social groups, family networks etc.)

Young Person Aware of Referral?:
YesNo

In your opinion, who would be the best person to make the initial contact with the Young Person?:
Who would be best to speak to the Young Person about this referral and our mentoring service? Please feel free to select more than one response.
Please select all that apply.

Any further information?:
Please use the space below to share anything else you think would be useful for us to know as we process this referral – including any other contacts that we should have.