Referral form Child Details Child's name DoB Gender Male Female Parent/Carer name Parent/Carer email Parent/Carer phone number Child's home address Referrer details Referrer's name Referrer's position Referrer contact number Referrer contact email Family details Status Both parents Lone parents Step parents Carer Other Please specify Siblings Any other information Does the parent/ Carer have parental responsibility? Yes No If no, who has parental responsibility? Is the child subject to a Child Protection Plan? Yes No Is the child subject to court proceedings? Yes No School details School name School address School contact name School phone number School email number Other details Funding - Please let us know how this intervention will be funded by ticking one of the boxes below: Self-funded Local Authority Funded ASF Funded Seeking Bursary Support Unkown - Please can I discuss this with someone Reasons for referral - Please provide a brief summary of your concerns. A full assessment will be completed at the commencement of this intervention Presenting behaviours/concerns Please indicate your preference to outreach or hub-based support as follows I would prefer the intervention to take place at the child’s school I would prefer the intervention to take place at The Purple Elephant Project Hub I do not have a preference For Hub-based support: - (please note, a responsible adult must stay with on site during child’s session) The child can attend the Hub during school hours The child can only attend outside of school hours * *Please note, this option will limit availability and may affect waiting times Any other information Signature by ticking you are confirming your submission of this form and aggreeing to our privacy policy Privacy policy Send
