Office use only: FAX: 0161 228 0528 Date referral form processed following incomplete referral Pending closure date http://42ndstreet.org.uk/referral following no contact from YP s/ Client ID 42nd Street Referral Form 2016 - for Professionals (referrals for young people 13+ years)

Has this referral been discussed and agreed by the young Yes No person?

Has the young person previously been referred to 42nd Street? Yes No

Date of Referral

YOUNG PERSON’S INFORMATION:

Title First Name Surname

Age Date of Birth

Gender: Male Trans Gender Queer / Non - Binary Male Female Trans Other gender identity - Female please state

Area of Residence: Manchester Tameside & Glossop Trafford Salford

Young Person’s Contact Details: Address line 1 Address line 2 Town Post code Telephone (1) Mobile Email

Permission to Contact Young Person: Ok to post mail to young person? Yes No Ok to phone Telephone (1)? Yes No Ok to phone mobile? Yes No Ok to text young person? Yes No OK to leave a voicemail? Yes No OK to email young person? Yes No Preferred way for us to contact young person? Please state

1 Is the GP the Referrer? Yes No

GP Details:

Name of GP Name of GP Surgery Address Post code Phone Number Email

Not registered with a GP (Please tick)

Referrer Details:

Name of Referrer Referrer Job Title/Role Name of Referrer Organisation Address Post code Phone Number Email

Referrer: GP Local Authority IAPT Service Hospital (inpatient services) School nurse A+E Gateway / Early Help Hubs / Bridge / Local Youth Offending Service Authority single point of access service Early Identification of Psychosis services Youth Justice Organisations Bereavement services Probation Voluntary sector Prison (drugs/alcohol): service (Please state name) Voluntary Sector Police (mental health) – (Please state name) Voluntary Sector Hostel / Supported accommodation (social care) – (Please state name) Crisis Services Job Centre, employment support agencies CSE services School (name) Arts organisations PRU/Alternative education SureStart FE Colleges Youth and community groups HEIs, including university counselling services Statutory Social Care Advocacy organisation CAMHS Advice Centre – legal, financial. AMHS Victim Support Early Help Service: SARC (please state name) Eating Disorder Service Refugee/ asylum support services

2 REFERRAL INFORMATION.

Can you tell us briefly about the difficulties / experiences which affect the young person’s mental health or emotional well-being?

Please tick any difficulties/experiences that apply.

Bullying Anger Discrimination e.g. religious, Exam stress homo/trans/biphobia, disability, racism Loneliness / isolation Cultural issues Homeless / at risk of homelessness Refugee or seeking asylum Anxiety (social anxiety & phobias) Confidence / self-esteem General Anxiety / Stress / Worry Health worries / concerns Obsessive Compulsive Disorder (OCD) Bereavement Panic attacks Disability Avoids going out (agoraphobia) Physical Health Depression Domestic Violence Self-harm Eating disorder Suicidal thoughts Sexual abuse Suicidal attempts Physical abuse Risk to others Emotional abuse Post-traumatic stress Neglect Psychosis (Paranoia, Hallucinations, Ritual / honour based violence e.g. schizophrenia, etc.) Female Genital Mutilation (FGM) Extreme of mood - bipolar Sexuality Family problems Gender identity Attachment issues / difficulties Miscarriage or Termination Friendship difficulties Sexual health concerns Other relationship difficulties Self-care issues Persistent relationship issues (includes Personality Disorders) Drug / alcohol misuse (own)

Challenging Behaviour

Please give details:

3 Can you tell us why the young person would like to come to 42nd Street for support?

Please give details:

What types of support or activities is the young person interested in at the moment?

Individual therapeutic support: includes counselling; Cognitive Behavioural Therapy (CBT); one-to-one support; and advocacy.

Creative and group work programme includes arts, identity, therapeutic, issue based groups and social action projects.

Both of the above

Not sure

If you would like to know more about 42nd Street, our individual therapeutic support or creative and group work programme, you can find more information on our website www.42ndstreet.org.uk or you can call us on 0161 228 7321.

Does the young person’s behaviour ever present a risk to them self or others?

Does the young person present any risk to others? No Yes

Does the young person self-injure or No Yes, often self-harm? Yes, sometimes Prefer not to say

Do they have suicidal thoughts? No Yes Prefer not to say

Have they attempted No Yes, Once Yes, more than once suicide? Yes, in the last 6 months Prefer not to say

Has the young person had any thoughts of suicide in the past 6 No Yes weeks that they have wanted to act upon?

Please give details:

4 Are there any other issues about their mental health that it is important for us to know at this stage: e.g.: physical health difficulties; medication prescribed by a doctor/psychiatrist; other crisis or risk issues, a formal diagnosis from a GP or Psychiatrist.

Please give details:

Is the young person receiving support from any other professionals or services? e.g. social worker; psychiatrist; psychologist, etc.

Yes No

Please give details:

Does the young person have any particular needs we need to be aware of when we contact them or offer them an appointment?

Please give details:

Appointment Preferences:

*Please be aware that preferences are not always available* Last available appointment 6.00pm at our office base on Mon, Tues, Wed & Thurs; 4pm on Fridays. Appointment time: Day Evening Either Preferred worker gender: Male Female Either Preferred Project Type: ‘Inside Out’ Disabled Young People’s project (LGBTQ+)

Please tick if the young person needs a community based appointment

5 Young Person’s Identity Information

Ethnicity: White- British Asian or Asian British- Pakistani White- Irish Asian or Asian British- Bangladeshi Any other White background Any other Asian background Mixed-White and Black Caribbean Black or Black British- Caribbean Mixed-White and Black African Black or Black British- African Mixed-White and Asian Any other Black background Any other mixed background Chinese Asian or Asian British Any other ethnic group Asian or Asian British- Indian Prefer not to say

Disability:

Not Disabled Multiple disabilities Physical disability Unseen/invisible disability e.g. epilepsy, asthma etc. Blind/partially sighted Asperger’s/ autism Deaf/hard of hearing Other Learning disability/difficulty Prefer not to say

Young carer for a parent/carer or family members: Yes No Prefer not to say

What Happens Next?

We will contact the young person to arrange an initial assessment and confirm the arrangements in writing. We will notify all referrers of the young person’s engagement with our service.

If you have any further questions regarding our services, please get in touch on 0161 228 7321.

If you would like more information regarding data protection or our confidentiality policy, please visit our website: www.42ndstreet.org.uk.

When you have completed this form please send it to us by post or fax.

42nd Street, The Space, 87 – 91 Great Ancoats Street, Manchester, M4 5AG

FAX: 0161 228 0528

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Outcome of Referral:

Admin: Referral Admin Date: entered onto database: Initials:

DUTY: Referral Not Disengagement Screening accepted / Form complete (Tick): and sent to Outcome: Admin (Yes):

Admin: Disengaged on database (Tick):

DUTY: Referral Accepted IM Geographical Text (No- Screening reply) confirmation of (Tick Urgent Case referral acceptance/will Outcome: relevant Management contact to book IM (Tick) route) Group only (no Group risk identified) name:

DUTY ACTION Accepted Group only Duty Worker (risk identified allocated IM to (Groups / risk – IM is (Fieldworker identified only) required) Name):

Engagement Worker: Initials: Date: Referral entered onto general waiting list / general groups or group specific waiting list as relevant (if no risk identified):

Engagement Worker: Following contact attempt No reply after 2 weeks, Unable to speak to YP to book IM / no response - close case and letter to offer an IM appt. text to yp (2 week reply sent to referrer saying window) (Tick) no service required. (Tick)

Engagement Worker: Date IM Appt and worker letter sent IM Booking time of name: to IM: confirm (tick)

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