Wcbc Housing Department

Action For Children Families First Transition Service

REFERRAL FORM

REFERRAL DETAILS Date of Referral

Referred by: Position:

Telephone No: Is the family aware of this referral:

Signature: YES / NO

PERSONAL DETAILS

Name: Date of Birth:

Address: Telephone No:

Family Members Within Household: Dates of Birth (Family Members within Household):

SUPPORT SERVICES

Family Doctor: Health contact:

Telephene No: Telephone No:

Social Worker: Other Agencies (Involved with the family):

Telephone No: Telephone No: So that we can offer the most appropriate support please complete the following table:

Tick if If ticked, please tell us why this is a need and how a appropriate support worker may be able to help. 1. Sign post and support disabled children, young people and families to appropriate services. 2. Support disabled young people to access work placements, post school learning opportunities, apprenticeship providers and future employers 3. Support with accessing and attending adult education courses 4. Support to find funding (e.g. Individual Learning Accounts), liaising with Colleges, Jobcentre +, Disability Teams, Careers Wales and other relevant agencies 5. Support practical solutions to remove barriers to accessing services 6. Travel / Transport issues 7. Assisting young people to access youth clubs and activities of their choice within the community and to enhance their independence and social skills 8. General Health & Wellbeing

9. Maintaining Relationships

10. Access to Barclays Money skills workshops and financial support 11. Empowering young people to develop social and life skills through group activities 12. General Advice & Counselling to empower young people and their families to seek support to enhance their emotional wellbeing.

Please add any additional information which you think we would find helpful. Also, please comment on any identified needs for the children/young people within this family. If necessary please continue on extra sheet.

Please indicate any useful information to safeguard against risk for this family:

To be completed by allocated FFTS Transition Worker on receipt of referral

Name of Transition Worker:

Referral Date:

Assessment Date:

How did you hear about us ? CONSENT FOR INFORMATION STORAGE AND INFORMATION SHARING

I/ We have received an explanation of the reasons for sharing personal information and I consent to information being shared with other agencies for the purpose of providing a service to my child

I / We consent to this referral being made to Families First Transition Service and consent to any other agencies on this form being held by Action For Children.

I / We also give consent for Families First Transition Service to contact other agencies for further information regarding this referral.

Signature or person referred :………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………… ……………………………………………………..

Signature of parent / Carers ( if person referred is under 18): ...... ………………………………………………………………………………………………………………… …………………………………………………….

All practitioners working with children and young people have a duty to share information when they or others have evidence that a child is being , or is at risk of being, abused or neglected (i.e Child protection)

Jude Vaughan , Action for Children, Arosfa, Greenside, Mold, Flintshire. Tel: 01352 700127 E mail: [email protected]