Interpersonal Trauma Response Service (ITRS) CYP REFERRAL FORM

Referring Clinician (Name)

Referrers Email Address

Practice Name

Child or Young Person’s First Name

Child or Young Person’s Last Name

Date of Birth

SAFE Telephone Number for the Patient

Is it safe to leave a message/text this number? --Select-- Yes No Unknown

Address 1

Address 2

Town

Post Code

Is it safe to post information to the above address? --Select-- Yes No Unknown

Name of School

Details of any additional needs

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Date of Birth

Parent/Guardian Phone

SAFE Parent/Guardian Email Address

Parent/Guardian Address 1

Parent/Guardian Address 2

Parent/Guardian Town

Parent/Guardian Post Code

Family already known to Social Services? --Select-- Yes No Unknown

Details of Social Worker

Reason for Referral to ITRS

Consider high risk factors: SPECSSS – Separation; Pregnancy: Escalation; Community Isolation; Stalking; Sexual abuse; Strangulation.

Does the patient consent to FearFree sharing details of their support with their GP? --Select-- Yes No Unknown