Youth Clubs

YOUNG PERSON’S DETAILS

CONTACT DETAILS FOR PARENT/CARER/GUARDIAN

SENDER OF THIS FORM

WHO SHOULD WE CONTACT DIRECTLY UPON RECEIPT OF THIS REFERRAL?*

Young PersonParent/FamilyProfessional

DOES THE PERSON YOU ARE REFERRING KNOW THAT YOU ARE CONTACTING GENERATE?*

YesNo

WHAT OPPORTUNITIES/SUPPORT HAS THE PERSON YOU ARE REFERRING EXPRESSED AN INTEREST IN?*

Youth ClubBuddy schemeHalf term/summer holiday activitiesOther(please state below)

PLEASE PROVIDE RELEVANT INFORMATION TO ENSURE WE OFFER THE APPROPRIATE SUPPORT

Does the Young Person have a disability?

Autistic spectrum disorder (ASD)Learning difficulties (LD)Physical disabilities (PD)Sensory impairment (SI)Social, emotional and mental health difficulties (SEMH)Other, please provide details below:

What is the reason for referral?*

What (if any) are the apparent risks posed by or to the Young person?*

Are there any ‘triggers’ we need to be aware of?*

Does the Young person have any of the following

Education, Health and care plan (EHCP)Common assessment (CAF)Statement of Special Educational NeedsDisability living allowance (DLA)Personal Independent payment (PIP)Other relevant assessment (please state below)

Are any other agencies working with the young person, If so who?

ConnexionsYouth Offending TeamTargeted Youth Support TeamSchoolEducation WelfareSocial servicesEducational PsychologistOther (please state below)

Is there any other information that will help us to provide support to the Young Person?*

What school/college does the young person attend?*

What is the name of their tutor or SEN lead?*

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