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Referring Organisation / Local Authority *
Job Title / Role *
Phone Number (Direct Line) *
Emergency / Out-of-Hours Contact (if applicable)
Team / Department
Gender Identity --- Choose from the list --- Male Female Non-binary Prefer not to say Other
Ethnicity --- Choose from the list --- Asian or Asian British Black, Black British, Caribbean or African Mixed or multiple ethnic groups White Other ethnic group
Legal Status * --- Choose from the list --- Section 20 Full Care Order Interim Care Order Emergency Protection Order Other
Social Worker Contact Phone *
Current Placement Type --- Choose from the list --- Foster care Residential home Hospital Secure unit With family Homeless/No fixed accommodation Other
Reason for Referral
Summary of Risks / Current Concerns *
Frequency and Severity of Risks --- Choose from the list --- Low Medium High
Frequency and Severity of Risks - Supporting explanation
Known Triggers
Successful Strategies / What Works Well
Emotional & Behavioural Needs Overview
CAMHS Involvement * --- Choose from the list --- Yes No
If yes provide details
Current Medications *
Therapeutic or Support Requirements *
Name of School / Provider
SEN / EHCP Status * --- Choose from the list --- Yes No Pending
Education Concerns
GP Name & Practice
Medical Needs / Conditions
Allergies
Hospital / Clinical Involvement
6: Triggers (Direct
Parent/carer Phone Number
Important Relationships
Cultural / Religious Needs
Type of Placement Requested --- Choose from the list --- Emergency placement Planned placement Solo placement High-support placement Medium/long-term placement Domiciliary / community support Other Choice 11
Reason for Placement Request
