Penumbra, Penumbra 1st Floor, 2 Kirk Wynd, Kirkcaldy, Fife, KY1 1EH T 01592 201 872 | F 01592 201 972 E [email protected]

PENUMBRA YOUTH PROJECT FIFE REFERRAL GUIDELINES Introduction These guidelines are intended for any individual wishing to make a referral or self referral to Penumbra Youth Project. The guidelines accompany the Penumbra Youth Project Referral Form and Risk Assessment. If you are a young person wishing to make a referral on your own behalf and you would like more information, or if you would like help completing the form, please contact us. Who can make a referral? Any person can make a referral to Penumbra Youth Project on behalf of a young person. This includes parents, guardians or other family members, social workers, community workers, health workers, GPs, teachers and voluntary sector workers. Young people may also self-refer to Penumbra Youth Project using the referral form or by contacting the office for assistance. Who can you make a referral for? Penumbra Youth Project will accept referrals for young people with mental health and mental wellbeing support needs. Young people should be aged between 12 and 21 years and live in Fife. Consent Penumbra Youth Project works with young people on a voluntary basis, and therefore will not accept referrals without the signed consent of the young person. Completing the referral form and risk assessment Referral forms and risk assessments should be completed fully, as incomplete forms cannot be accepted. Next of kin details are required, but will only be used in what Project staff judge to be an emergency situation. Where risk is identified, either to or from the young person, further information should be given, and actions taken to minimise risk should be described. Access to service provision Access to service provision will depend on two factors: The level of need of the young person. The availability of the service required. Because of the high demand for the services we provide all referrals are prioritised as they are received. Once a referral has been made we will look at the information provided in the referral form and risk assessment. We will decide from this if the young person is perceived to be a high enough priority and if we have sufficient capacity to proceed. If the young person is not perceived to be a high enough priority or we do not have the capacity to proceed with the referral we will get back to you to let you know at the earliest opportunity. Please note - we do not maintain a waiting list for our services. If we are unable to proceed with your referral and you still feel that Penumbra Youth Project offers a service that is required we ask that you re-present the referral at a later date – either where the young person’s circumstances have significantly changed or at least 3 months after the date of the initial referral.

PENUMBRA YOUTH PROJECT FIFE REFERRAL FORM Date of referral _____________ Young Person’s Details Name: Address:

Referral No. (Project Use)____________

M/F

Referrer’s Details Agency/Service: Address:

Postcode: Referred By: Contact Address (if different from above) Position: Date of Birth: Contact Tel No: Mobile No: Email: Doctor’s Details Name: Address:

Age:

Tel No.

Tel No.

Ethnic Group: 1 2 3 4 5 6

African Asian Caribbean UK Euro Other Euro Other-please specify ______________

Urban/Rural 1 2 3 4

Type of Accommodation 1 2 3 4 5 6 7 8 9 10 11 12

Family Home Single Accomm Tenancy Support Homeless With Friends Residential School Residential House Foster Care Halls Hospital Prison Other-please specify ____________________

Contact No: E-mail: Parent/Guardian Details (under 16) Next of Kin Details (over 16) Name: Relationship: Address:

Rural Village Small Town Large Town

Area 1 2 3 4 5 6 7

Source of Referral 1 2 3 4 5 6 7 8 9 10 11

Self S/W Housing Criminal Justice G.P. Com Team Education Police Voluntary* NHS* Other*

Kirkcaldy Levenmouth Glenrothes Dunfermline Cupar North East Other- please specify ___________________________

Status

1 Employed 2 Unemployed 3 Pupil/Student Please specify School attended

_____________________ 4 Volunteer 5 Other-please specify __________________________

Other Service/Agency Contact Name of Agency/Service

Tel No.

Contact Name

Reason for Referral

Signed (referrer)

_________________________

Date: ______________

Please note your referrer will be informed if you cancel or do not attend meetings Signed (young person)

_________________________

Date: ______________

Referrals will not be accepted without the young person’s signature Action (project use)

Please return to: Penumbra Youth Project 1st Floor, 2 Kirk Wynd, Kirkcaldy, KY1 1EH

phone: 01592 201872 fax: 01592 201972

24: Risk Assessment to be completed by Referrer Potential Risks To Referred Service User As part of Penumbra’s Referral process, we require you as referrer to complete this form. If at all possible, please involve referred service user in the process and ask them to sign. The information on this form will enable us to ensure our staff are best equipped to deliver appropriate quality support to the Service User. Any information contained in the risk assessment will be classed as third party information and therefore confidential. Please complete to the best of your knowledge. Please note the term Service User means any people who will potentially use our support services .

1. Details Name of referred Service User

Date of Birth of referred Service user

Address of referred Service User

Relationship to referred Service User

Name of person making initial referral

Address & Contact number of referrer

Penumbra’s Risk Assessment Ratings L : Low risk - Low priority / No or Low level of action required M : Medium risk – Medium priority / medium level of action required H : High Risk – High Priority / Urgent/ immediate action required

2. Potential Risks To Referred Service User Tick if not Applicable

1. 2. 3. 4. 5. 6. 7.

Not eating or drinking properly Poor Personal Hygiene Substance Abuse Unsafe smoking / Fire risk Isolation / Loneliness Not shutting/locking door Unsafe crossing road

Low / Medium / High (Please circle if applicable)

L L L L L L L Tick if not

Mobility

Personal Safety 11. Suicidal Ideas 12. Self Harm Ideas 13. Abuse by others • Verbal • Physical • Sexual • Financial • Emotional 14. Unsafe with Gas/ Electrical appliances

H H H H H H H

Low / Medium / High

Applicable

8. Falls 9. Wandering during day-time 10. Wandering during night-time

M M M M M M M

(Please circle if applicable)

L L L

M M M

H H H

Tick if not

Low / Medium / High

Applicable

(Please circle if applicable)

L L

M M

H H

L L L L L L

M M M M M M

H H H H H H

24 Risk Assessment to be completed by Referrer

Potential Risks To Referred Service User ctd Other relevant factors or expansion & where risk has been identified in any of sections 2 – 4 please describe any actions taken to minimise these. (If required, please add dated and signed separate A4 sheet with appropriate heading number eg 2.6)

3. Potential Risks From Referred Service User Has the Referred Service User, in your experience or to your knowledge, any history of : (Please circle as applicable) 1. 2. 3. 4. 5.

Criminal Convictions (spent or current) or actions pending ? Violence ? Physical Aggression ? Sexual Disinhibition ? Anti Social behaviour ? • Has an Anti Social Behaviour Order been granted against the referred service user (or anyone living with them) ? * Yes – Court action was taken * Yes – Less formal action was taken (eg a written warning) 6. Is the referred service user required to register with the police under the Sexual Offences Act 2003 ? 7. Other (please state below or on separate sheet)

Yes Yes Yes Yes

No No No No

Yes*

No

Yes

No

Yes

No

Other relevant factors or expansion on the above & where risk has been identified in Section 3 please describe any actions taken to minimise these. (If required, please add dated and signed separate A4 sheet with appropriate heading number eg. 3.6)

In my experience and to my knowledge, the above statements and those on separate sheets are true. Referrer’s Signature _________________________

Referred Service User’s signature ……………………………………………………………… Referred Service User’s name ……………………………………………….(Block Caps please)