Referral Form For Admission to Children's Home

1: Child's Personal Details

Child's Initials (required) - Do not enter full name

Age

Gender (required)

MaleFemaleTransgenderNon-binary/non-conformingPrefer not to say

Current Town or County

Current Living Arrangements

Section 2: Referrer's Details

Full Name of Referrer (required)

Relationship to Child/Family

Contact Phone Number

Email Address (required)

Agency/Organization (if applicable)

Address of Agency/Organization

Section 3: Family and Background

Parent(s)/Legal Guardian(s) Initials

Parent(s)/Legal Guardian(s) Town/County

No of Siblings

Relevant Family History

Legal Status of the Child

Section 4: Reasons for Referral

Detailed overview of the reasons for this referral

What are the expected outcomes of this placement?

Section 5: Child's Needs and Strengths

Specific Needs (e.g., emotional, behavioral, developmental, social)

Child's Strengths and Interests

Any specific cultural, religious, or dietary needs

Does the child have any pets? (required)

YesNoNot sure

Section 6: Health and Medical Information

GP's Surgery Name

Known Medical Conditions or Disabilities

Current Medications

Allergies

Mental Health History (if applicable)

Details of any mental health professionals involved

Section 7: Education and Social History

Is the child currently in education? (required)

YesNoNot sure

Current School/Educational Setting

Last Date of Attendance

Any Special Educational Needs (SEN) or support plans

Child's Social Network (e.g., friendships, connections with family)

Any involvement with social services or other support agencies

Section 8: Declaration

I, the undersigned, declare that the information provided in this referral form is accurate to the best of my knowledge.

Print Name

Date

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