Young person referral form (Milton Keynes)

Please be aware this form can't be saved as you go. Due to the length of the form you may wish to draft your answers separately first.

Basic details

Young person's name

Date of birth

Ethnicity

Gender

Postcode of home/main residence

Client/young person’s contact details

Contact details for parent/guardian, if aware of referral

School or college attended

Please write 'none' if the young person is not in education.

Identity

If you ticked any of the above, please record details below.

If they are known to social care, please provide name and contact details for their social worker.

If yes, please give further details below.

Disclosures

If you selected 'they do not feel safe' above, please give more details here.

Age of current partner (if applicable and known)

Number of sexual partners they have had (if known)

Relationships

If you answered yes above, please state whether they were victim or perpetrator.

Please give further details below.

Home life

If you answered yes above, please give further details below.

Reasons for referral

Please state your specific concerns and reasons for referral

Referrals will only be considered if the reasons for referral meet the criteria for the 1:1 programme.

Please provide us with as much information as it is appropriate or relevant to share. Any details of current or historic social care or police involvement must be disclosed if not detailed elsewhere.

Please note lack of information or explanation regarding key concerns may result in a referral being declined due to lack of information.

The 1:1 programme is an education intervention and is not counselling. If the client/young person requires mental health support we would recommend an alternative referral to a counselling service.

For schools

Please only fill in this section if the young person is being referred from a school setting.

If not, please skip to the Referrer Information section below.

Name of school or academy

Contact details for named professional within school (if different to referrer)

Referrer information

Name

Job title

Organisation

Contact number

Contact email

Please type your name below to sign that you confirm this referral

Countersigned by young person to give consent for referral.

Location

Your proposed location for 1:1 sessions to take place

Is there any further information you feel it would be helpful for us to know?

For example, regarding availability or engagement.

Safeguarding lead

Please fill this in with your own details if you are the organisational safeguarding lead.

Please tick to confirm that it has also been shared with the organisational safeguarding lead.

Organisational Safeguarding Lead name

Organisational Safeguarding Lead email

Terrence Higgins Trust reserves the right to decline any referrals that do not meet our criteria, or that we feel would be more appropriate to another service.

We endeavour to respond to new referrals within 10 working days, but under specific circumstances this may take longer.

We do not work with young people currently receiving support from another service, or who are the subject of a current, open police investigation.

For any queries or concerns regarding making a referral, please contact [email protected].

Search the site

Need to find help?