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Black Country Holistic Approach

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					                Black Country Holistic Approach
                               Client Referral Form


Staff Name (person making the referral)

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Clients Name _____________________________________________________________

Address ____________________________________________________
________________________________________________________________________

Residency at this address since (exact date please) ___________________

Telephone Number: ___________________ Mobile              ____________________

Gender:     Male      Female             D.O.B ____/____/____          Age _________

Ethnicity: ______________________________

Nationality:__________________           Main Language: __________________


Current Status: _________________ Registration Number:____________

Date Granted: ____/____/____

Referral From Org: ________________ Contact Person _________________

Date ____/____/____              Telephone: _______________________________

Provision Requested.
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Purpose. Integration, Alternative education, social inclusion, behavioural, identity.
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Risk Assessment              Low           Medium                High


Reasons Forming Assessment
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Outcome required
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Previous experience or qualifications.

School ____________________________ from ____________ to ___________
College____________________________ from ____________ to ___________

Employment skills
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Interests and Hobbies
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Start Date given ___________________________ Review Date _____________________
Information Sharing protocol in place signed dated and approved     Yes     No


Health and Medical details - Is the client reasonably fit. Yes    No
Please disclose any known (1) illnesses      (2) allergies   or (3) On medication
(please tick)


Allergic to __________________________________________________________
___________________________________________________________________


Please state medication ________________________________________________
___________________________________________________________________

How many times a day and at what

Interval ________________________required _________________times a day


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Emergency Contact Number (friend, relative, key worker)
Name
______________________________________________________________________________


Address__________________________________________________________________

_________________________________________________________________________

_________________________________________________ Post Code: ______________


Telephone Number: _______________________ Mobile:_________________________


Relationship
____________________________________________________________

Language Spoken _________________________ Can speak English Yes                   NO

Please add any information that may be relevant to aid or hinder your client’s integration.
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Has funding of your clients place been agreed? Yes       No        Term       Full year

By whom: _______________________________________Date_______________________

Signature of purchaser. (Head teacher or other) ______________________________________


Signed by Staff member: ________________________________

Position: __________________________________ Date_______________________



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     Please return all completed forms marked Private & Confidential to;

                   Richard Clarke, Director of Operations,
                      Black Country Holistic Approach,
                  Market Street, Wolverhampton, WV1 3AR.

               Telephone: 01902 717165 Mobile: 07792816488
                       Email: rac_hac@yahoo.co.uk


Office Use Only. notes

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Signature: _______________________________________Date_______________________

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