Make a referral About you All about you and your family/carers Name/s * Date/s of Birth * Gender you identify with * School you attend & contact * Home address & Postcode * Best way for us to contact you? (mobile number is best) * Disability * - Select -NonePhysicalLearningCommunicationLanguage Ethnicity * - Select -Asian or Asian British PakistaniAsian or Asian British IndianAsian or British Other AsianBlack or Black British AfricanBlack or Black British CaribbeanBlack or Black British SudaneseBlack or Black British OtherChineseMixed White Black AfricanMixed Other ParentageMixed White AsianMixed Parentage / Heritage WhiteMixed White CaribbeanWhite BritishOther WhiteIrishTraveller of Irish HeritageGypsy / RomaOther Ethnic GroupNot Known Do you require an interpreter? * Yes No If yes, what language? Do you consent to having an advocate? * Yes No Meetings Do you have any important meetings coming up that you need an advocate to support you at? Please state date, time and location. Initial Child Protection Conference Review Children Protection Conference Me and My World Review Other (please state) Referral Details Referrer Name * Referrer Contact Details * Date of referral * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20192020202120222023 Pod Number * Who supports you? Who are the best people to contact who are involved in your care? Eg Parent, social worker, IRO Contact Role Name Contact details Are you happy for us to contact these people? Yes No Additional Contact Role Name Contact details Are you happy for us to contact these people? Yes No Additional Contact Role Name Contact details Are you happy for us to contact these people? Yes No Advocacy What would you like an advocate to do for you? You have the right to the support from a Youth Advocate if you are: (please pick which one applies to you) * - Select -Young Person in CareA young person with a disabilityYoung person attending a Family Group ConferenceYoung Person subject to a child protection planA young parent under 18 (or up to 25 with SEN)Unaccompanied asylum seekerCare leaver (up to age 25) What would you like to get from having an advocate? (please select ‘yes’ to as many as you want or add something that’s not here) 1. To make sure your views, wishes, opinions and feelings are listened to Yes No 2. Your views and feelings are passed onto meetings about your life Yes No 3. Tell people you are unhappy about something/make a complaint Yes No 4. Confidently speak for yourself in meetings Yes No 5. Change something like your social worker, place to live or carer Yes No 6. See more or less of someone Yes No 7. Get your stuff back Yes No 8. Get a decision made in your favour Yes No 9. Feel happier about what’s going on Yes No 10. Other - please describe… Are there any other important things you want to tell us…
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