LIFT referral form

Before you begin

You can only make a referral to LIFT if you are a professional supporting families, and have consent from a parent or person with parental responsibility.

Please complete this form with the parent/carer of the young person you are referring.
Are you a professional supporting families?
YesNo

Unfortunately, you can't make a referral

We can only accept referrals from professionals supporting families.

You can contact LIFT for information about managing children’s challenging behaviour at home.

Your details
Your first name
Your last name
Your email address
Your phone number
Service/organisation
Please select your profession

Please tell us your profession

Parent or person with parental responsibility
Full name of parent / person with parental responsibility
Parent's date of birth (DD/MM/YYYY)
Have you had consent from this person to make a referral?
YesNo
Other parent or person with parental responsibility (optional)
Full name of parent / person with parental responsibility
Parent's date of birth (DD/MM/YYYY)
Have you had consent from this person to make a referral?
YesNo

Unfortunately, you can't make a referral

We can only accept referrals if consent has been provided by a parent or person with parental responsibility.

You can contact LIFT online if you would like more information.

Parent's contact details
Please provide the parent's contact details so that we can contact one of the parents if needed.
Parent's contact phone number
Parent's email address
Parent's address
Address line 1
Address line 2
Address line 3
Address line 4
Address line 5
Postcode
Young person's details
Young person's full name
Young person's date of birth (DD/MM/YYYY)
Please tell us which of the following most accurately describes the young person or if you'd like to provide more information

Please provide more information about the young person.

Please select the young person's preferred language

Please tell us the young person's preferred language

Ethnicity
What is the young person's ethnic group? Choose one option that best describes your ethnic group or background.
Asian or Asian British
IndianPakistaniBangladeshiChinese
Any other Asian background, please describe:
Black or Black British
AfricanCaribbean
Any other Black, African or Caribbean background, please describe:
Mixed or Multiple ethnic groups
White and Black CaribbeanWhite and Black AfricanWhite and Asian
Any other Mixed or Multiple ethnic background, please describe:
White
Welsh / English / Scottish / Northern Irish / BritishIrishGypsy or Irish Traveller
Any other White background, please describe:
Any other ethnic group
ArabOther
Any other ethnic group, please describe:

Young person's main address
Please provide the young person's main address.
Address line 1
Address line 2
Address line 3
Address line 4
Address line 5
Postcode
Are there any other people living at the property with the young person and parent(s) or people with parental responsibility?
YesNo

Details of other people living in the household
Please let us know the details of any other people living in the household, including the relationship to the young person and if they have a disability

Has the young person provided consent to this referral being made?
YesNo

Please provide details of why the young person refuses or is unable to give consent

Education
Please select an option that best describes the young person's current education
Young person attends a school in ConwyYoung person attends a school in DenbighshireYoung person attends a collegeYoung person is home educatedYoung person is not attending a school or college and is not home educated

Conwy schools
Which school does the young person go to?

Denbighshire schools
Which school does the young person go to?

Colleges
Which college does the young person go to?

Please tell us the other school or college the young person attends

Does the young person receive any additional support at school/college?
YesNo

Please tell us about the additional support at school/college

Is the young person currently receiving help from any other therapeutic services?
YesNo

Please tell us which therapeutic services are currently providing help (tick all that apply)
Behaviour ServiceCAMHSChild and Adolescent Learning Disability Service (CALDS)Early Years Nursing TeamFamily Wellbeing ServiceNeurodevelopmental ServicesOccupational TherapyPhysiotherapySleep ClinicSpeech and LanguageOther

Please tell us which other therapeutic services are currently providing help

Is the young person on a waiting list for any other therapeutic services?
YesNo

Please tell us which therapeutic services the young person is on the waiting list for (tick all that apply)
Behaviour ServiceCAMHSChild and Adolescent Learning Disability Service (CALDS)Early Years Nursing TeamFamily Wellbeing ServiceNeurodevelopmental ServicesOccupational TherapyPhysiotherapySleep ClinicSpeech and LanguageOther

Please tell us which other therapeutic services the young person is on the waiting list for

Has the young person received any other therapeutic services in the past?
YesNo

Please tell us which therapeutic services/behaviour support the young person has received in the past (tick all that apply)
Behaviour ServiceCAMHSChild and Adolescent Learning Disability Service (CALDS)Early Years Nursing TeamFamily Wellbeing ServiceNeurodevelopmental ServicesOccupational TherapyPhysiotherapySleep ClinicSpeech and LanguageOther

Please tell us which other therapeutic services the young person has received in the past

Young person's health
Please provide as much information as possible and if you can, please upload any recent health or clinic letters.
Please provide details of the young person's GP, Health Visitor, School Nurse and Paediatrician
Please tell us about any known health conditions or diagnosis the young person has
Please upload any recent health or clinic letters

Is the family/young person under social services?
YesNo

Please provide more information about the family/young person being under social services

Is the family/young person under any child protection services?
YesNo

Please provide more information about the family/young person being under child protection services

Does the family/young person have any other social care teams involved?
YesNo

Please provide more information about the other social care teams involved

Is there any significant life events or stressors affecting the family/young person at the moment?
YesNo

Please tell us about the significant life events or stressors affecting the family/young person at the moment

Please select any of the following that is impacting on the life of the young person or family
Challenging behaviourEating patternMotivationPeer relationshipsRelationshipsSchool attendanceSleep patternSubstance MisuseOther

Please tell us what else is impacting the life of the young person or family

What is the parents/carers/professionals biggest concern at present?

Please select any of the following that is being shown by the young person
Disruptive BehaviourPhysical AggressionProperty DestructionSelf-Injurious BehaviourSensory concernsSexually Inappropriate BehaviourStereotypic/Repetitive BehaviourVerbal Aggression
Please provide more information about the behaviours selected or let us know about any other challenging behaviour being shown
Please let us know any tools/strategies used to manage these behaviours

Home visits
Please let us know if there are any potential risks we should know about in case we decide to visit the young person's home e.g. any lone worker policy
Please select any of the following risks that may come up if we visit the young person's home
AnimalsChild protection/family issuesDifficult accessIsolated areaSocial services involvementSubstance abuseViolence
Please provide any other information we should know about if we visit the young person's home.

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