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Referral form

Young person’s details

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Has consent been obtained from
Which of the following issues are relevant to the young person being referred? (Please tick all that apply

Referrer’s details

Consent of young person and parent(s) /guardian

EYES operates within a very strict confidentiality/data protection policy and as such requires the full agreement of both the young person and parent(s)/guardian. It is the responsibility of the referral agency to obtain ‘informed consent’ from young person and parent(s)/guardian.

Please put NA in the next two box below if does not apply for this referral

Parents(s)/Guardian details

Young person’s view on the referral: NA in box if does not apply

Risk Assessment: Please tick all that apply

It is crucial that important background information is disclosed by the referrer. This is to ensure that the young person gains the maximum benefits from our organisation while ensuring the safety of the young person, staff, and other participants.

Other agency involvement.

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