Young Person Transport Booking Form

Name of person making this booking

Telephone number

Email address

From (where are you calling from?)

Local Authority

Purchase order no.

Billing authority

Name of social worker (where applicable)

Contact number of social worker (where applicable)

Email address of social worker (where applicable)

Name of young person

Date of birth

Gender Male Female

Is the young person on A secure order A mobility order DoLS order Other

If other, please specify

Is the young person aware that they are being transported? Yes No

Are there any known risks? Yes No

Aggression Low Medium High

Violence Low Medium High

Self harm Low Medium High

Absconder Low Medium High

Any additional risk, please specify

Has the young person been given any medication which could cause additional risks? Yes No

If yes, please specify

Date of transport

Pick up time or ASAP ASAP — as soon as possible

Collection address

Postcode

Contact name at collection

Telephone number at collection

Destination address

Postcode

Contact name at destination

Telephone number at destination

How many staff do you require PSS to provide? Driver only Driver plus one support worker Driver plus two support workers Driver plus three support workers

Additional requirements or information

PSS Secure Transport

Young Person Transport — Booking

Pick up information

Destination information