Main Heading in 16Pt Verdana Bold / Purple s1

Rochdale Children’s Rights Service Professional’s Referral Form

Do you have permission from the young person to refer? Please fill in all sections of the form and send it to us at – Yes No The Children’s Rights Service The Children’s Society 94-96 Hilltop Drive If no please gain permission before Kirkholt sending in this form Rochdale, OL11 2RL (If the young person is unable to give Telephone - 01706 345600 permission due to disability please indicate Or email us on: [email protected] in the additional needs section)

Official Use only – not to be completed by referrer

Date Referral Received

Advocacy Worker Allocated

Name of young person requiring Date of Birth of Young Person advocacy Age 0 Gender Male Phone number of young person Is the young person looked after by Rochdale Metropolitan Borough Council or a care leaver in their own tenancy? Yes No Please note - if no the young person is not eligible for this service Name of young person’s Social Please tell us the looked after status Worker of the young person

Voluntary Accommodated (Section 20) Interim Care Order (Section 30) Care Order (Section 31) Care Leaver Other – Please specify - Name of young person’s Does the young person Independent Reviewing Officer Live with Local Authority foster carers

Live in a Local Authority children’s home Live with Agency Foster Carers Live in Private Children’s Home Own tenancy/supported living (care leavers) Please tell us the nature of the advocacy issue

Does the young person have any additional needs? Yes No If yes please specify –

Are there any risks associated with the young person? E.g. is there any reason an advocacy worker should not meet the young person alone?

Name of Referrer Address of referrer

Position of referrer – e.g. social worker/carer etc

Phone number of Referrer

Date of referral

Thank you – we will contact the young person to make an appointment. Please note you may not be informed of the outcome of the meeting. This depends on whether the young person gives us permission to discuss their issue with you.