Children & Young Person’s Referral Form

Which school or educational establishment does the young person attend:

Name of the main point of contact within the school:

Job role of the main point of contact for the child or young person at school:

Telephone of the main point of contact for the child or young person at school:

Email of the main point of contact for the child or young person at school:

If the child or young person is currently receiving support from an alternative organisation, or you are a professional referring from another agency, please complete the below:

What is the name of the organisation providing alternative support / referring the child or young person:

Name of the main point of contact for this organisation:

Relationship to child or young person:

Telephone of the main point of contact for for this organisation:

Email of the main point of contact for this organisation: Please tell us anything you think we should know about the type of support or agencies around the child or young person:

In making this referral, I confirm that I have discussed Pete’s Dragons support with the young person, their parent / guardian, the school and any other relevant organisations providing support to the young person. In ticking this box I am indicating that all parties are aware that the referral is being made and have given verbal consent for Pete’s Dragons to make contact regarding support. Tick to confirm

Refer a child or a young person

Tell us a bit about yourself and the current support network around the child or young person

Tell us a bit about the child or young person you are referring

Tell us a bit about the person who has died

Thank you

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