CONFIDENTIAL WHEN COMPLETE
Fireplay Intervention
Referral Form
Please complete this referral form with as much detail as possible. Today’s Date:
Young Persons DETAILS
Male
Female
D.O.B:
First Name: Surname:
Other Names:
Current Address:
Previous
Address(s)
(Last 5 years)
Post Code:
Previous
Post Code:
Identified Medical Problems (eg:
ADHD etc.)
Which school do they attend?
Hobbies / Interests?
Any siblings at same address?
Name(s) and age(s)
Any other siblings
not at this
address?
Name(s) and age(s)
Please give details of any incidents caused by the young person and any other necessary information.
(Please state if the incident occurred inside or outside and what was involved, including previous fire service
intervention)
PARENT / GUARDIAN DETAILS
Parent / Guardian Name:
Contact Number:
CONFIDENTIAL WHEN COMPLETE
Please tick to confirm that the parent/guardian have agreed to have their details passed to CDDFRS
REFERRER DETAILS
Name:
Job title:
Organisation name & address:
Contact email and phone number
Are any other agencies involved
with the fire setter?
Yes No
If yes, please give details:
1) What does the referrer want from this Intervention? Aims MUST be clearly stated.
2) Please describe the risk of harm to self and others (including fire service personnel) of the young person.
3) Does the young person have any mental health conditions? If so, please provide full details about all
agencies currently working with the young person.
4) Is the young person already in the criminal justice system and/or have on-going criminal proceedings?
Once this form is complete, please send to Community Risk Management:
By Email:
csenquiries@ddfire.gov.uk For assistance in completing, telephone: 0845 223 4221
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome