Referral Form

Date of Enquiry

Dealt with By
Name of Enquirer
Local Authority
Phone Number
Fax
Email
Address
Social Worker
Phone No. Fax
Address
Team Manager Phone No.
Name of Child Gender D.O.B. Age Ethnic Origin Religion

Child's previous address

Other Information

Linked
If not, why not?
Exemption Completed?

I agree that this match of child and carer is appropriate.

Duty managers signature


Duty referral Continuation sheet

Some of the information to seek should include

  • Type of placement required and when placement is needed.
  • Has the child suffered a placement breakdown previously, if so why?
  • What will be the expectations of contact?
  • Are there any health issues?
  • Are there any education issues?
  • Can we place the child with – children of the opposite gender
  • Younger children
  • A single carer
  • Does the child have a history of – substance abuse
  • Fire raising
  • Physical abuse of others/bullying
  • Racist or discriminatory language
  • Has the child experienced sexual abuse or abused others?