Dialogue Confidential Referral Form:Secondary School / College - YMCA DownsLink Group
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Dialogue Confidential Referral Form:
Secondary School / College

Dialogue Confidential Referral Form: Secondary School / College

"*" indicates required fields

Referrer details

Referrer's name*

Counsellor Details

Counsellor's name*
Due to privacy considerations ymcadlg.org addresses only please. Use of email addresses outside this domain will result in form information being lost.

Student Details

Name*
DD slash MM slash YYYY
Parent(s) / Carer(s) Name

Current issues including family, school, friendships:
Has this referral been discussed with the young person?*
Have the parents/carers of the young person been involved in the referral process?*
Are there any ongoing Child Protection concerns regarding this student?*
Is the student on the Child Protection Register?*
If YES, please answer the following
What category:
Social Worker contact details:
 
Does the student have an Education, Health & Care Plan?*
Does the student have any known learning difficulties/ disabilities?*
Does the student have any known medical conditions?*
Is the student taking any prescribed medication?*
Does the student have a diagnosis? E.g., autism, ADHD*
Is the student known to self-harm?*
Is the student having suicidal thoughts?*
Has the student made any attempts to end their life of which you are aware?*
Does the student receive any other school support e.g. learning mentor / pastoral support?*
Any history of conflict between parents/families/carers and school staff?*
Are they currently receiving private therapy?*
Are they under any CAMHS teams, including The Duty Team?*
Pupil Premium?*
Are any other services working / have worked with this student?
Social Services*
GP*
YOT*
Police*
Educational Psychologist*
Early Help*
Other Service (enter details below):*
Comments made about the service are sometimes used in promoting our work but will remain anonymous.
This field is for validation purposes and should be left unchanged.

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