Youth Support Team Early Help Request Form

Complete the form and send to either:

· youthsupportteam@prospects.co.uk or

· The Community Team, The Vibe Youth Support Centre, Druids Lane, Stanway Road, Gloucester, GL4 4RE

· If you wish to talk to someone about your referral you can call 01452 415707 however you will still need to complete a referral form to action a request.

If the concerns are of an urgent nature, i.e. a child appears to require immediate protection, contact:

· Children & Families Helpdesk (8am – 5pm) 01452 426565

· Emergency Duty Team (5pm – 8am)01452 614758

Young Persons Details

Name

Date of Birth (D.o.B)

Age

Religion

School/College/Training Provider

Language

Interpreter Required

Ethnicity

Yes / No

Disability/Special Needs:

Gender

Current Address:

Postcode:

Telephone No:

Family Composition

Name

Age/DoB

Relationship to Young Person

Ethnicity

Member of the Household

Telephone No. (parents)

Yes/No

Yes/No

Yes/No

Yes/No

Awareness and Consent

I understand and consent to this referral being made, on my behalf, to Gloucestershire Youth Support Team (YST).

I accept that, in order to support me, the YST will securely and confidentially hold my personal information.

This information may be shared with other services outside of the YST if the YST feel that there is another partnership agency (Social Care or Families First for example) that may be able to provide support if the YST are not able to.

I accept that the YST have a legal duty to share my information if there are concerns of harm from others towards me (safeguarding).

The information in this referral will be stored securely on the Youth Support Team’s database.

Please understand that the Youth Support Team will not contact a young person who is not willing to engage in this referral.

Is young person willing to engage with this referral process?

Yes / No

Young person signature

Young person’s full name

Is parent/carer aware of request

Yes / No

Parent/Carer Signature if appropriate/required

Parent/Carer full name and contact number

If ‘No’ to any of the statements above, please state your reasons (i.e. Your decision made to override the need for consent):

Requestor Details

Name of Requestor:

Agency/Role:

Email Address:

Telephone:

Postal Address:

Current Date Submitted:

Other Agencies/Professionals and GP involved with the young person/family

Name

Agency (Are they the Lead Prof/Agency?)

Role

Contact Details

Referring Agency/Professional involvement with young person/family

Is this young person currently open to your service?

Open/Closed

Date of closure:

What continued support are you providing to the young person?

Reason for request

Reason for Referral (please tick all those which apply) stating the nature of concern or perceived risk.

Education Training and Employment (post Year 11)

Substance Misuse

Low Level CSE, Keep Safe, Emotional Resilience

Anti-Social Behaviour

Crime Prevention

What outcomes are you seeking for this young person in relation to the above?

All requests for a service and general enquires will go through the Community Team. A request for service will be considered and we try to respond to the referrer within five working days. We may respond in any of the following ways:

· We will return any request for services without the young person’s consent or if the form is incomplete.

· We may not feel we have a role to play in which case we will contact you and let you know why. We will only make contact with the young person and their family if we feel we have a role to play. Otherwise we expect the referrer to notify the young person and their family of the outcome of the request.

· We may signpost you onto other services/organisations.

· We may already be working with the young person in which case we will let you know who the worker is and share your request for a service with them.

· We may agree to meet the young person and offer a triage at which point we will agree the next steps with the young person and their family and we will let you know what has been agreed.

· If a young person is NEET (post year 11) we will allocate a NEET worker.

CONTACT: The Community Team 01452 415707 or youthsupportteam@prospects.co.uk

Document owner: Gerard Calvert

Published on: 12/03/2019

Version: 3.0