Professional Referral

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Name:

minlen1Please insert your name parent / guardian
Address:

minlen1Please insert your address
Postcode:

minlen1Please insert your postcode
Email:
Telephone / Mobile:

minlen1Please insert your telephone / mobile number
Name of Child / Young Person:

minlen1Please insert the name of the child / young person
D.O.B.:

minlen1Please insert the date of birth of the child / young person
Please state other members of your family:

Name DOB School / Employment Relationship
Referring Agency:

minlen1Please insert your Referring Agency
Address:

minlen1Please insert your Agency Address
Telephone / Mobile:

minlen1Please insert your Agency telephone / mobile number
Reason for Referral:

500 characters remaining

minlen1Please insert your Agency Address

Please specify the service you require by ticking one bow below:

ADD NI Parenting Programme: Please indicate preference	10.30am - 12.30pm	6.30pm - 8.30pm
Young People Group Intervention Programme	7-9 Years 13-15 Years 10-12 Years 16+ Years
Individual Counselling (For Adolescents and Adults)
Art Therapy
Sibling Group Programme

Family History/Relevant Background:

500 characters remaining

minlen1Please insert your Family history
Please tell of any significant events which have occurred within the family:

500 characters remaining

minlen1Please insert any significant events
Name of Family GP & Contact Address/Telephone/Mobile Number:

500 characters remaining

minlen1Please insert contact details for your GP
Name of Consultant/Community Paediatrician/Psychiatrist/Psychologist involved:

minlen1Please insert your Consultant/Community Paediatrician/Psychiatrist/Psychologist
Any other Pending Assessments:

Yes: No:
Is the Young Person currently involved in other forms of intervention?

Yes: No:
If YES, please specify:
500 characters remaining
Medication, Please state type and dosage levels (if applicable):
500 characters remaining
Social Work Contact with Family, if any:
500 characters remaining
Profile of Young Person (Social, Emotional, Physical & Educational Development, Interests or Peer Relationships:
500 characters remaining
Any Considerations to Race, Religion, Language and Culture

Yes: No:
Family’s view of Referral
500 characters remaining
Young Person’s View of Referral
500 characters remaining
Safety/Risk Factors (For client and others)
500 characters remaining
Practical Considerations (Such as Disability, Significant Dates etc):
500 characters remaining
Problems as seen by the family (Please ensure that this section is discussed with the family prior to completion):
500 characters remaining
Other relevant information:
500 characters remaining
Signature of Professional:

minlen1Please insert your signature
Position:

minlen1Please enter your positon
If your require any further information please feel free to contact us. You can find all of our contact information on this page.

Apply for Services

Name	DOB	School / Employment	Relationship
Please state other members of your family: