YPS Befriending Online Referral Form

Hand of Solace

Young People's Service Befriending Referral Form

Before completing and sending in this referral, please ensure that you have read our befriending guideline and eligibility which you can find here:https://www.handofsolace.co.uk/youngpeopleservice. Please complete all the fields to avoid any delays in assessing your referral.

(Please note that incomplete forms will be returned to referrer).

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Address

Child's Phone no

Child's Email Address

Child's GP Name and Address

GP'S Email

GP's Phone No

Child's School/Academy Name and Full Address

Contact Person From Child's School

Name of Referrer (the person completing this form)

Phone No of Referrer

Email of Referrer

Relationship to Child

Do the child currently live with parents? Yes or No.

Full Name and Address/Adresses of Parents?(If the child live with parents).

Full Name , Address and Phone No of Child Main Carer?(If the child do not live with parents).

Please tell us about the child's current health and wellbeing situation:

Current network of support(Family Resource Worker, Social Worker, if any),Friends ,Family Member etc. which you feel may be relevant:

Befriending Objectives:

What do you hope the Befriending Service involvement will achieve? Please tick the top three that most apply:

Reduced feelings of Isolation:

Reduced feelings of anxiety:

Improved levels of wellbeing:

Improved levels of self-esteem/confidence:

Improved quality of life:

Increased independence:

Increased social links:

Improved Attachment Skill

Assistance with a personal goal:

Reduced Impact of Poverty

Is the child currently involved/attending any extra curricular activities. Yes or No ? If yes, please give full address of location, name of contact person and their phone number.

Please give details of anyone we can contact in case of concern (Relative, Any Health and Social Care Professional etc). Please supply name, email address, postal address and telephone number:

To ensure your child is able to participate and enjoy a range of opportunities during their befriending, we ask that you complete the following health information. Any information that you give about a child’s disabilities or health condition will be used to help volunteers/befriender make befriending more accessible for your child. We recommend that you speak to the befriending coordinator about support and adjustments the service can provide.

Compulsory Field

Do you consider your child to be disabled or to have a health condition? This could include physical impairments, learning difficulties or disabilities, mental health difficulties, sensory impairments, or any other medical conditions including epilepsy, asthma and diabetes. If your child would benefit from adjustments in order to help her participate fully please speak to the befriending coordinator.

Disability or Health Condition

Befriending meeting activities can often involve equipment, materials and food. Therefore please add any allergies or dietary requirements here.

Please state whether in your opinion it is safe for the child referred to be taken out of their home on escorted visits Yes or No?

Have you carried out a risk assessment for this child? (completed by a Health or Social Care Professional) Yes □ No □

Is there anything else we should know?

Will you be able to be present on the initial assessment and matching visit? (Please note that the referrer or a family member (19 years and above) must be present on the initial assesment visit. If the referrer will not be present, please supply contact details of who will be).

Please remember that we will not accept referrals unless permission to refer and to pass on information has been given by the child's main carer. Have you obtained permission from the child's main carer to refer this child ? Yes or No?

We sometimes take photos and/or videos during our activities. Please indicate below your preference for the way in which we can use the photos of your child.

[a] ‘Hand of Solace charitable activities are funded by different organisations who support the work we do. To provide evidence of our work to support our service users, Photos/videos can be shared and published and used for service promotion - this means I am happy for photos, videos, storytelling and other visual and audio content of my child to be taken/collected, used for promotional/evidence purposes, published in public-facing media and shared within Hand of Solace and with partners and local newspapers’.

[b] ‘Photo/videos can be used for Hand of Solace use only - this means I am happy for photos, videos, storytelling and other visual and audio content of my child to be taken/collected, used as a record of befriending activities, not published in any public-facing media and not shared outside the Hand of Solace’. This may include Hand of Solace specific social media channels (that are closed to the public).

[c] ‘Do not take photo/videos - this means I do not want photos, videos, storytelling and other visual and audio content featuring my child to be taken’.

Photo/video permissions differ for large scale events (where over 100 participants are present). Consent forms will state clearly if an event is large scale, and will request parent/carer to tell befrienders/Befriending coordinator if they do not wish photos/videos of their child to be taken at the event.

Risk Assessment:

Does the child have any criminal convictions? Yes or No ?

If yes, please provide details of conviction

Areas of risk to self (if there is a known risk to self, please give full details)

Areas of risk to others (if there is a known risk to others please give full details)

Additional Information (is there other relevant information or areas of concern that we need to be aware of eg unusual or aggressive behaviour?)

Your information shall be assessed to meet the requirements for the service. The referral shall be assessed within 14 days and we shall contact you whether or not you do meet the eligibility , if we have any spaces, or if more information is required.

Please Note: Hand of Solace operates an equal opportunities policy therefore every application will be prioritised and assessed following the service assessment criteria which you may find on the service page on our website.

Upload any Risk Asessment that have been conducted for the referee(if any)

Upload any Risk Asessment

Upload any supporting document that you may want to draw our attention to for the referee(if any)

Upload Any Supporting Document

I agree to the terms & conditions

• I have provided information that is complete, true and accurate to the best of my knowledge and belief and

I have obtained an appropriate consent from the child's main carer to disclose all personal information within this application to Hand of Solace Young People Befriending Service in accordance with -Hand of Solace Privacy Policy, Principles on Personal Data and Principles of Data Protection, see- https://www.handofsolace.co.uk/privacy-policy-and-data-protection

Date

Your referral has been submitted!