Oak Lodge Residential & High Support Fostering Service. Chapel Street, Carrick-on-Suir, Co. Tipperary, Ireland. (Please tick the type of placement required) Residential Care Name of H.S.E. Local Authority making referral: This referral has been formally approved for placement by the appropriate H.S.E. local authority and funding agreed. PLEASE ENSURE ALL SECTIONS ARE COMPLETED. Page 1 of 9
Page 2 of 9
Include young person’s view of referral to residential/foster care. Specify reasons for referral to
residential care/foster care.

For example, specialist educational programmes, relative/ foster placements, residential placements, level of supervision, reason for placement changes/breakdown. Page 3 of 9
For example, family members, family dynamics including ability to supervise/control young person’s behaviour, parenting practices, quality of relationships, contact between parents, siblings and relevant persons, cultural heritage of family, language spoken at home. Not applicable if included in the social background report which is enclosed. Page 4 of 9
For example physical description, social skills, personality, interests, attitudes, anti-social behaviour. Page 5 of 9
For example, current school, previous schools attended and reason for change, level of achievement, behavioural issues, relationships with other pupils/teachers, educational psychologist. Receiving any medical treatment from doctor, Page 6 of 9
Allergies to medication (e.g. penicillin) Other relevant information: E.g. Medical Card Include specific details of offending behaviour with/without charges, substance misuse, fire raising, and sexually aggressive behaviour. Include previous and current involvement of agencies in relation to behaviours, for example, addiction workers, educational psychologist, specialist counselling. Page 7 of 9
(Tick those that you are inclosing with this form) Educational Report (including co-ordinated support plans) Psychological/ Psychiatric/ Medical Reports Page 8 of 9
Please return the form to:

Name: Sean Brennan. Director of Services.
Address: Oak Lodge Residential Services, Chapel , Carrick- on Suir, Co. Tipperary.
Fax: 051/649150. Telephone: 051/ 641723
Email: [email protected]
Name: Louise Lehane. Head of Fostering Services.
Address: Oak Lodge High Support Fostering Services, Chapel, Carrick- on Suir, Co. Tipperary.
Fax: 051/649150. Telephone: 051/ 641723
Email: [email protected]
N.B. Please note, should the young person being referred be accepted into the care of Oak Lodge
Residential and/or Fostering Services, the following documentation will be required prior to
Page 9 of 9

Source: http://www.oaklodgefostering.ie/Oak%20Lodge%20Referral%20form%202009.pdf

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