Spotlight

Referral Form

Confidential

Details of referred person - please use the young person’s full name

Young person’s first name *

Young person’s last name *

Preferred name / Nickname

Gender *

Date of birth *

Last school/college attended *

Address of young person *

Postcode *

Telephone (Mobile) *

Telephone (Home)

eEHA / Statutory assessment in place? *

Yes

Reason for referral

What is the main reason for referring the young person?

What change would you like to see in the young person as a result of this referral?

Please provide information on the young person’s current situation and support needs with reference to the following areas.

Health & development

General health, mental health, drugs & alcohol, education, aspirations

Parents & carers

Describe the young person’s relationship with parents/carers

Does the young person consent to sharing information with parents about this referral? *

Yes

Not Sure

Are parents/carers aware of this referral and the situation the young person is facing? *

Yes

Not Sure

Family & environmental

Family history, social & family relationships, well-being, housing, employment, financial situation

Referral agency and other partners/professional involvement

Details of referral agency

Name of agency/organisation making the referral *

Name of referrer *

Agency address *

Postcode *

Telephone *

Email *

Referrer Signature *

Clear

Date *

Consent

Has the young person named on this referral form consented to a referral to Spotlight and for information to be shared amongst Spotlight partners?

Consent has been obtained? *

Yes

If No, is young person aware of the referral? *

Yes

If you are human, leave this field blank.

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