Professionals 1:1 support referral

Please ensure you have permission from the child’s parent/carer to share this information before completing this form.

Please complete as many of the details below as you can but feel free to leave spaces blank if you don't yet have this information. Thank you.

Details of Child / Young Person

Full Name of Child / Young Person:

Date of Birth (00/00/0000) and age:

Is this child / young person a Scotty's Member?

YesNoI don't know

Consent from Child / Young Person? Would they like support?

YesNoI don't know

Details of Parent/Carer

Full Name of Parent or Carer:

Relationship to child/ren:

Do you have consent from the Parent/Carer to make this referral?

YesNo

Address:

Email Adress:

Contact Telephone Number:

What does support look like?

Please give as much detail as possible.

What other services and interventions have been involved?

Are there any risks? (to themselves, to others or from others)

What are the main concerns for the young person? What are their concerns? (what do you think the problem is? Where does the problem occur? Does anything make the problem better or worse? Are concerns shared with anyone else? How long has this been going on for?

What is going well? (Strengths/positive, hobbies, support that has been useful? Friendships?)

What are you / Parent / Carer / Child / Young Person, hoping to get from the support?

Any other notes to be considered for the referral:

Communication Preferences

Do you or they have any communication preferences or require any reasonable adjustments to be made? (i.e. prefer all communication to take place by email or phone)

YesNoI don't know

If yes please provide further details:

Can a message be left on an answerphone?

YesNoI don't know

Referral completed by:

Organisation:

Full Name

Email Address:

Contact Telephone Number:

Your role and involvement with the child or young person:

Thank you for your referral. Scotty's Little Soliders will contact you and may need to get further supporting information from you. All information is held in line with GDPR and Data protection Regulations.

Your Rights Under GDPR