Social Services Referral Form

* Name of Young Person:

* Date of Birth :

Day:  Month:   Year:

Legal status:

Immigration status (if applicable):

Name and address of Solicitor:

Telephone number:
incliding the area code

Name of the allocated social worker:

Social Services Department:

Professional address:

Office telephone number Managers office number
including the area code

Young Person's History

Please supply information and details
Family
Past Placements
Education/Employment
Health
Racial and cultural background
Please provide information on the young person's interests/hobbies etc.

Has the young person had experience of sharing with his / her peers? If so, was it successful? Why/why not?

Yes      No

Krossroads policy is to take on young people regardless of any history of criminal activity, such as arson, drugs or any offences against the person. To provide sufficient support The Project requires full details of any offences.

Has she / he been found guilty of acts or incidents of violence?

Yes No

If yes, please explain giving the nature of the offence(s), and the outcome of any court appearances.

Do any of the above offences constitute the young person being classified as a Schedule 1 Offender?

Yes No

Does the young person have outstanding Court appearances?

Yes No

If yes, give full details, including dates.

Krossroads policy, in the majority of cases, is to develop a Placement Plan for a minimum of 6 months.

In your assessment of the young person's needs, what are the areas you feel they require support in, and how many hours would they require per week to achieve a reasonable level of independence?

Are you aware of any reason why the young person is not eligible for Housing Benefit or Income Support?

Yes No
If there is, please give reasons .

Please write the young persons National Insurance Number .

If there is any further information relevant to this referral not covered in the previous points concerning the young person, please add in the space below.

Yes No