Make a referral to BDP Youth Team

Referrer's Details

Name*

Relationship to young person*

Contact address*

Address Address Line 2 City State / Province / Region Post Code Country

Phone*

Mobile*

Email*

Please tick the boxes to confirm that:*

The young person is aware of the referral
The young person agrees to be referred and engage with support

As referrer, you agree to be available for contacting in regard to this referral by BDP for a period of two weeks after receipt of referral.*

I have read and understood.

Young person's details

Name

Has the young person ever been known by any other name? If yes, please state:*

Home address*

Address Address Line 2 City State / Province / Region Post Code Country

Gender*

Date of birth*

Is the young person in care or a care leaver?*

Yes
No

Is the young person a young carer?*

Yes
No

Mobile*

E-mail and/or social media

Primary Carer’s contact details

If the young person named above is under 13 years of age, parents/carers need to be aware of the referral.

Is the young person aged 13 or under?*

Yes
No

If yes, are the parents aware of the referral?*

Yes

Primary Carer 1

Name*

Relationship to young person*

Tel/mobile/email*

Primary Carer 2

Name*

Relationship to young person*

Tel/mobile/email*

Further details

Name of education/training/employment provider, if applicable*

Details of any LDD or other disability*

Current risk factors youth workers should be aware of (e.g. violence, drug use, dangerous pets in the house etc)*

Other agencies involved currently or in the recent past with the young person and/or family that we should know about?

Please include the name of the organisation, the name and contact details of the worker, the nature of support, the duration and reason of ending support for each of the agencies that have supported this young person recently.

Has the young person experienced any Adverse Childhood Experiences (ACEs)? Mark all that apply:*

Physical abuse
Sexual abuse
Emotional abuse
Living with someone who used/uses drugs
Living with someone who used/uses alcohol
Exposure to domestic violence

Please provide details if applicable:

Which of these issues is the young person experiencing? (Please tick all that apply)*

Drug and/or alcohol use
Drug and/or alcohol use within the family (Child affected by substance use)

Referrer's Details

The following boxes need to be completed in full for the referral to be assessed:

Please state the reasons for the referral*

What does the referrer hope this intervention will achieve?

Young person’s views and expectations on the referral. What support would the young person like to access?*

What are the young person’s hobbies or interests? Any other relevant/useful information?*

What happens next?*

I understand that by completing this form, the details I have provided above will be taken, saved and stored by BDP for data protection reasons, namely, to provide one-to-one support to young people. I have been advised that if I want more details about how BDP deals with my information, I can ask to see the full Privacy Notice.

BDP will assess the information provided and will contact the person named above as the referrer within two weeks from confirmation of receipt of this form to discuss the next steps.

Make a referral to BDP Youth Team

Make a referral to BDP Youth Team

Referrer's Details

Young person's details

Primary Carer’s contact details

Primary Carer 1

Primary Carer 2

Further details

Other agencies involved currently or in the recent past with the young person and/or family that we should know about?

Referrer's Details

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