Foróige Project Referral Form
Project Salesforce ID
Project Details
Name of Project
Project Type
Please select...
Drug Education & Prevention
Health & Wellbeing
Mentoring
Youth & Communities
Youth & Family Support
Youth Crime Diversion
Youth Employability
Youth Participation
Education Programmes
Volunteer Led Services
Project Subtype
Please select...
Peace Plus
UBU
Other
Referral Details
Referral agency:
Referral agency address:
Reason for referral
Referred by
Role
Phone
Home Phone
Email
Parent/Guardian has consented to the referral
Please select...
Yes
The young person has expressed an interest in attending the project
Please select...
Yes
No
Type of Youth Diversion Project (YDP) Referral
Please select...
Early Intervention (8-11)
12-17
Participant Details
First Name
Surname
Street Address
Town/City
County
Please select...
Antrim
Armagh
Carlow
Cavan
Clare
Cork
Derry
Donegal
Down
Dublin
Fermanagh
Galway
Kerry
Kildare
Kilkenny
Laois
Leitrim
Limerick
Longford
Louth
Mayo
Meath
Monaghan
Offaly
Roscommon
Sligo
Tipperary
Tyrone
Waterford
Westmeath
Wexford
Wicklow
Eircode
Eircode finder:
https://finder.eircode.ie/
Postcode
Gender
Please select...
Woman or Girl
Man or Boy
Prefer not to say
Prefer to Self Identify
'Man or Boy', 'Woman or girl' refer to an individual's internal sense of being male or female, respectively
x
Gender - Self Identify
Date of Birth (YDP Early Intervention)
Please ensure that you have selected the correct Type of YDP Referral, based on your young persons needs and age
Date of Birth (YDP 12-17)
Please ensure that you have selected the correct Type of YDP Referral, based on your young persons needs and age
Date of Birth (TI)
Please ensure that you have selected the correct Type of YDP Referral(12 - 17)
Date of Birth
Mobile (Aged 12+)
Email (Aged 12+)
Don't put a space at the beginning or end of the email!
Involvement in Clubs/ Groups
Parent / Guardian Details
First Name
Surname
Relationship to young person
Please select...
Mother
Father
Guardian
Same address as young person?
Street Address
Town/City
County
Please select...
Antrim
Armagh
Carlow
Cavan
Clare
Cork
Derry
Donegal
Down
Dublin
Fermanagh
Galway
Kerry
Kildare
Kilkenny
Laois
Leitrim
Limerick
Longford
Louth
Mayo
Meath
Monaghan
Offaly
Roscommon
Sligo
Tipperary
Tyrone
Waterford
Westmeath
Wexford
Wicklow
Eircode
Postcode
Phone (preferably mobile)
Email
Don't put a space at the beginning or end of the email!
Email
Don't put a space at the beginning or end of the email!
Family Circumstances
Participant Education
Name of School, College, or place of Further Education
Class/ level
Participants current engagement in Education (e.g. attendance)
Participant Behaviour
Any behavioural issues Foróige should be aware of?
What are the young person's hobbies and interests?
YDP Areas of Concern (Early Intervention)
While you may not have information for each of these categories, please indicate the areas of the young person's life where you may have concerns:
Family Circumstances
Community causing issues for the child e.g. unsafe community
The relationship between caregiver and child is strained
Issues with family circumstances affecting the child (can include, family experiencing considerable stress)
Issues with parenting strategies (current strategies not working)
Child Circumstances
Child struggles with self-control
Child has experienced trauma that may still affect them
The child has inappropriate/negative peer relationships
Child expresses anti-social values and thinking
Child engaged in anti-social behaviour
Please outline reason(s) for referral with reference to the areas indicated above (Early Intervention)
YDP Areas of Concern (12-17)
While you may not have information for each of these categories, please indicate the areas of the young person's life where you may have concerns:
Family Circumstances & Parenting (e.g. relationships, supervision, boundaries, discipline, behaviour)
Education/Employment (e.g. behaviour in classroom /at school, relationships with peers and teachers, academic achievement, truancy etc.)
Peer relations (e.g. pro-social or anti-social friends or acquaintances)
Leisure/Recreation (e.g. involvement in recreational activities, use of leisure time)
Personality/Behaviour (e.g. physical/verbal aggression, attention span, frustration tolerance, feelings of guilt/remorse, self-esteem)
Attitudes/Orientation (e.g. pro-social/antisocial attitudes, attitude towards authority, empathy, recognition of a problem with behaviour, accepting help)
Please outline reason(s) for referral with reference to the areas indicated above (12-17)
Any other Relevant Information
e.g. other agencies involved
Please outline any other relevant information indicating any strengths in the young person and /or their circumstances, other agencies involved, diagnosis, etc.
JLO Specific Information
Are you the Juvenile Liaison Officer (JLO)?
Please select...
Yes
No
Most Recent Offence Type
Date of Offence
Has The Participant Been Cautioned?
Please select...
Yes
No
Type of Caution
Please select...
Formal
Informal
Caution Detail:
Please provide details of any prior cautions, involvement of the young person with the Courts, Probation Services, or Detention
Data Protection Statement for Referring Agency
Personal Data Processed by Foroige
I understand that the personal data provided on this form regarding the data subject will be processed by Foroige for the purposes of determining whether or not to accept the referral.
Your
personal data will be processed by Foróige according to Foróige's Data Protection Policy and in accordance with the Data Protection Act 2018. Please go to the Foróige Website for more information on Foróige's Privacy Policy.
YDP 12-17 Agreement
On receipt of this form contact will be made with the parent/guardian and the young person to conduct a brief screening assessment to aid in assessing suitability for intervention. As the referral agent, you may be contacted by the project for additional information. Not all young people referred to the project will be admitted. If this is the case, where possible, alternative services will be suggested. As the referral agent, you will be informed of the outcome of this referral.
I have read and agree to this.
YDP Early Intervention Agreement
On receipt of this form and following an assessment of suitability for Early Intervention, contact will be made to the parent/guardian advising if the young person has been deemed suitable for Early Intervention. As the referral agent, you may be contacted by the project for additional information. Not all young people referred to the project will be admitted. If this is the case, where possible, alternative services will be suggested.
I have read and agree to this.
Final step is to review and submit the form. You can also print your responses if required.
Contact Information