Make a Referral

Client Information

Application Form - Life

1. The Young Persons Information
2. Previous Placement History
3. Family Information
4. Young Persons Team Details
5. The Young Persons Profile
6. Emotional and Behavioural Development
7. Desired Outcomes
8. Desired Outcomes (Continued)

Date of Application:

Forenames:

Surname:

Date of Birth:

Gender:

Nationality:

Ethnicity:

Religion: (optional)

Language:

Current Address

Interpreter Needed: (optional)

Yes

Doctors' surgery details:

Please state the borough that the young person was born in: (optional)

Current borough young person resides: (optional)

Immigration Status:

Legal Status:

National Insurance Number:

NHS Number:

Is the young person able to claim Housing Benefit? (optional)

Email Address;

Contact Number:

Next of Kin:

Contact details for next of kin:

Previous Placement History (optional)

(Please fill out the previous placements that the young person has resided with)

Start Date:

End Date: (optional)

Provision Name and Address:

Provision Type:

Legal Status in placement: (optional)

Reason for Leaving:

Previous Placement History 2 (optional)

Previous Placement History 2

Start Date: (optional)

End Date: (optional)

Provision Name and Address: (optional)

Provision Type: (optional)

Legal Status in placement: (optional)

Reason for Leaving: (optional)

Previous Placement History 3 (optional)

Previous Placement History 3

Start Date: (optional)

End Date: (optional)

Provision Name and Address: (optional)

Provision Type: (optional)

Legal Status in placement: (optional)

Reason for Leaving: (optional)

Previous Placement History 4 (optional)

Previous Placement History 4

Start Date: (optional)

End Date: (optional)

Provision Name and Address: (optional)

Provision Type: (optional)

Legal Status in placement: (optional)

Reason for Leaving: (optional)

What is the history of the young person? (optional)

Please give a detailed outline of the young person’s history.
Please note that the information provided gives us as a team a clearer insight to the young persons history and current presentation.
Please input as much information that you have for us to assess the young person’s background as accurately as possible.

Please give a detailed outline of the young person’s history. Please note that the information provided gives us as a team a clearer insight to the young persons history and current presentation. Please input as much information that you have for us to assess the young person’s background as accurately as possible.

Please state the young person's current presentation? (optional)

A few pointers to help create this information should include: the current state of the young person's mental health, behaviour, relationships, education, is the young person working etc. all information in this section should help us understand how the young person is currently navigating through life.

Please state the young person's current presentation?

What are the young person's aims?

Please indicate the young person’s risks and provide a clear understanding of this risk? (optional)

What support is already in place for the young person? (optional)

Has the young person have any diagnosis? (optional)

Please enclose the young person's family details? (optional)

Please include the young person's birth parents if this information is available and any family the young person is in contact with.

Forename: (optional)

Lastname: (optional)

Relationship to child (optional)

Address (optional)

D.O.B (optional)

Ethnicity (optional)

Religion (optional)

Language (optional)

Family details 2 (optional)

Forename: (optional)

Lastname: (optional)

Relationship to child (optional)

Address (optional)

D.O.B (optional)

Ethnicity (optional)

Religion (optional)

Language (optional)

Family details 3 (optional)

Name (optional)

Forename: (optional)

Lastname: (optional)

Relationship to child (optional)

Address (optional)

D.O.B (optional)

Ethnicity (optional)

Religion (optional)

Language (optional)

Family details 4 (optional)

Forename: (optional)

Lastname: (optional)

Relationship to child (optional)

Address (optional)

D.O.B (optional)

Ethnicity (optional)

Religion (optional)

Language (optional)

Please state the young person's main career details? (optional)

Please note the carer should be who has current custody of the young person.

Name:

Local authority:

Job title:

What is the relationship to the young person:

Email:

Contact number:

Social Worker Name:

Social Workers Office Number:

Social Workers Office Email:

Social Workers Local Authority:

Social Worker Team:

Social Worker Team Managers Details:

Emergency Duty Team Contact Details:

Has the child/young person been involved with the Safeguarding team?

Details if applicable

Has the child/young person been involved with the SEN team?

Details if applicable

Has the child/young person been involved with the YOS team?

Details if applicable

Has the child/young person been involved with any other Specialist Services?

Details if applicable

Young Person Profile (optional)

Profile of Young Person: What are the positive attributes of the Young Person? What are they good at? Include likes/dislikes and strengths/achievements.

Education of Young Person: Please state what school the young person currently attends, if they have an EHCP or SEN and if there are any special requirement for them.

Hobbies and interests: What do they enjoy? Do they attend any clubs or groups?

Special requirements for the placement e.g. allergies, dietary requirements, disabled access

Contact arrangements. What contact arrangements will be in place? Are there certain people the child cannot contact? Are any orders in place? Are there any special requirements for contact (i.e. interpreters)?

Voice of the Young person: What do they want to happen? What do they think about moving? (If appropriate, please ask the child to complete this section)

Please share if the young person has behavioural and/or emotional concerns with the outlined behaviours below: (optional)

Unauthorised Absence / going missing

Criminal /Anti-Social Behaviour

Sexualised Behaviour (optional)

Fire Setting Behaviour (optional)

Self-harms (optional)

Involvement with gangs (optional)

Carries / use of knives (optional)

Harms Animals (optional)

Overdosing (optional)

Other (please specify) (optional)

Multi-Agency Comments (optional)

All relevant professionals who know the young person should be given the opportunity to comment on and influence planned placement moves. As such, this referral form should be shared with relevant partners and their comments added to the box below (optional)

Desired Outcomes (optional)

SAFETY: Children and young people are protected and feel safe.

This section refers to the child’s ability to feel safe, secure and protected by adults who are acting in their best interest. Consider ways that the child could adopt safe practices at home, school or in their community (keeping themselves and others safe).

Select outcomes from below drop downs (optional)

Specific details of the outcome to be achieved (optional)

Select outcomes from below drop downs 2 (optional)

Specific details of the outcome to be achieved 2 (optional)

Select outcomes from below drop downs 3 (optional)

Specific details of the outcome to be achieved 3 (optional)

List any other related outcomes (optional)

HEALTH (optional)

HEALTH: Children and young people experience the highest attainable standards of physical and mental health.

Children and young people need access to suitable healthcare, as well as support so that they learn to make healthy choices themselves. In addition to minimising the risk of illness and injury, consider how the child can maintain good physical and mental health (i.e. nutrition, exercise, hygiene, immunisations, access to health professionals they trust).

Select outcomes from below drop downs (optional)

Specific details of the outcome to be achieved (optional)

Select outcomes from below drop downs 2 (optional)

Specific details of the outcome to be achieved 3 (optional)

Select outcomes from below drop downs 3 (optional)

Specific details of the outcome to be achieved 3 (optional)

List any other related outcomes (optional)

ACHIEVEMENT (optional)

ACHIEVEMENT (INCLUDING EDUCATION): Children and young people are learning and developing their skills.

This section should outline key educational outcomes and any support the young person requires to achieve them. Consider opportunities to make use of the child’s skills/talents and how these achievements can be celebrated

Select outcomes from below drop downs (optional)

Specific details of the outcome to be achieved (optional)

Select outcomes from below drop downs 2 (optional)

Specific details of the outcome to be achieved 2 (optional)

Select outcomes from below drop downs 3 (optional)

Specific details of the outcome to be achieved 3 (optional)

List any other related outcomes (optional)

Desired Outcomes (Continued) (optional)

FUNCTIONING: Children and young people have appropriate control over their own lives and the ability to build and sustain supportive relationships. Consider how this child can be supported to make appropriate decisions over their life. Consider how the young person can be helped to develop good relationships and sustain friendships.

Select outcomes from below drop downs (optional)

Specific details of the outcome to be achieved (optional)

Select outcomes from below drop downs 2 (optional)

Specific details of the outcome to be achieved 2 (optional)

Select outcomes from below drop downs 3 (optional)

Specific details of the outcome to be achieved 2 (Copy) (optional)

List any other related outcomes (optional)

PERSONAL RESOURCES (optional)

PERSONAL RESOURCES: Children and young people have the ability to deal with life’s difficulties (resilience), feel good about themselves (self-esteem) and understand both their emotions and the emotions of others (emotional intelligence). Consider the specific outcomes which would most help to improve the child’s resilience, self-esteem and emotional intelligence

Select outcomes from below drop downs (optional)

Specific details of the outcome to be achieved (optional)

Select outcomes from below drop downs 2 (optional)

Specific details of the outcome to be achieved 2 (optional)

Select outcomes from below drop downs 2 (Copy) (optional)

Specific details of the outcome to be achieved 2 (Copy) (optional)

List any other related outcomes (optional)

IDENTITY AND SOCIAL PRESENTATION (optional)

IDENTITY AND SOCIAL PRESENTATION: Children and young people have a strong and positive sense of self and are comfortable with their identity. This section should look at the child’s identity and their social presentation needs, strengths and difficulties. This can include aiming for a positive sense of his/her ethnicity, consideration of religious, spiritual and/or culturally specific needs and life story information.

Select outcomes from below drop downs (optional)

Specific details of the outcome to be achieved (optional)

Select outcomes from below drop downs 2 (optional)

Specific details of the outcome to be achieved 2 (optional)

Select outcomes from below drop downs 3 (optional)

Specific details of the outcome to be achieved 3 (optional)

List any other related outcomes (optional)

PREPARATION FOR ADULTHOOD (optional)

PREPARATION FOR ADULTHOOD: Young people can maximise their independence and self-determination, feel included and positively contributing to community life. In this section, think about the future. What activities/outcomes would prepare the child or young person for their transition to adulthood and independence? This does not just apply to those approaching their 18^th birthday, as preparation for adulthood should commence from early in the teenage years (i.e. life-skills).

Select outcomes from below drop downs (optional)

Specific details of the outcome to be achieved (optional)

Select outcomes from below drop downs 2 (optional)

Specific details of the outcome to be achieved 2 (optional)

Select outcomes from below drop downs 3 (optional)

Specific details of the outcome to be achieved 3 (optional)

List any other related outcomes (optional)

Please summarise the three most important outcomes you would like this placement to achieve for this child/young person

Psychological Treatments (optional)

(Please indicate if the young person is or has engaged in any psychological treatments such as: psychotherapy CBT, occupational therapy, drug and alcohol support groups).

Type of treatment (optional)

When did this treatment start (optional)

When did this treatment end (optional)

Address of treatment (optional)

Name of the specialist (optional)

Is the young person taking medication?

Medication name (optional)

First prescribed (optional)

Time taken (optional)

Strength (optional)

Route (optional)

Frequency (how many times take) (optional)

Any further information that we should take into consideration please specify below:

Save draft

LIfe Vision

LIfe Glossary

Secure Base

Q&A

Referrals and Admissions

Employment and Training

Concern and Complains

Ask us a Question

LIFE Model of Intervention

OLIVIA Okonkwo

Dean Whittington

Jay Morally

LIFE Gallery

Documents

Our Interventions

LIFE Model

Psychologically Informed Practices

Individual and Family Therapy

Young Persons 7 year Transformation Program

Case Formulation

Zone of Promo development

Open Space Mindfulness

LIFE Guardian

LIFE Interests

Psychologically informed Environments

Chalk Hill Blue

Building Critical Insight

LIFE Staff Training Manual

Practice with us

Enhancing Our Learning

Feedback and Testimonials

Environment Suitability

Reciprocal Relations Building

Talk to Us

Contact Us

LIFES Book Store

Shop

Cart

Checkout

Tutorials

Job Application Form

Chat Forum

Testimonials

Feedback

Blog

Blog

Cookie Policy

Terms and Conditions

Refund Policy

Privacy Policy

Client Information

Application Form - Life