Parent / Carer 1:1 support referral
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 Young Person
Full name:
Date of Birth (00/00/0000) and age
Consent from Child / Young Person? Would they like support?
Yes
No
I don't know
Details of Parent/Carer
Your full name:
Address:
Email Address:
Contact Telephone Number:
Best time to contact you:
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 or your child hoping to get from the support?
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)
Yes
No
I don't know
If yes please provide further details:
Can a message be left on an answerphone?
Yes
No
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