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					                                                                                    On completion of this form please return
                                                                                    to:

                positivefutures                                                     Positive Futures
                                                                                    Sports Development Service
                                                                                    County Hall
   FORM FOR REFERRAL TO                                                             Beverley
    POSITIVE FUTURES (10 – 16 years)                                                HU17 9BA

Please complete all information or referral will not be accepted.                   Tel: 01482 392532
 Young Person Details

   Young person’s name:                                                             Gender:      Male/ Female

   Date of birth:                                    Ethnicity:
                          /   /
   Contact address
                                                                  Telephone (home):

                                                                  Telephone (work):

                                                                  Telephone (mobile):
                              Post Code:
                                                                  Email:

   Disclosed disability:                                          Trakrekord Number:
                                                                  (if applicable)

   Name of school/college/training provider



 Referral Information

 Referring Agency……………………………………………………………………………………………………….
 Contact Name………………………………………….                                Tel……………………………………………………

Nature of Young Persons Needs
 Please give all relevant background information to ensure the maximum enjoyment and safety of the young
 people and members of staff involved in the project.
 Violence
 What is the likelihood of the young person demonstrating violence?
 Remote        Possible           Likely       Inevitable
 Who is the violence likely to be directed at?
 Staff (Male/Female/Both)         Young People (Male/Female/Both)      Both
 Please note any known triggers for this…………………………………………………………………………..
 Substance and alcohol misuse
 What is the likelihood of the young person being under the influence of substances or alcohol while attending
 activities?                                           Details of substances being used:
 Remote        Possible           Likely       Inevitable
 Child Protection
 Are there any child protection issues staff should be aware of? …………………………………….

 Education
 Does the young person require additional support with written work, please give
 details……………………………………………………………………………………………………………….

 Any additional information, please attach.
Is the young person aware of this referral? YES                                                   NO
Young Persons Comment on Referral
 Views and expectations:



 Brief outline of activities interested in taking part in:



 I also understand that my details will be put on a database and shared with other agencies where appropriate.
                                                                                    Client signature:…………………………………..


Reason for Referral
Please tick all appropriate boxes and state the level of ‘risk’ for the young person above.
YOT
 Received YOT disposal or equivalent pre-YOT
 Previous convictions resulting in community penalties.
Social Services
 Accommodated by voluntary agreement with parents (s20 CA 1989)
 Subject to a care order (s31 CA 1989)
 Remand to LA accommodation (s23(1) CYPA 1969)
 His/her name has been placed on the child protection register
 Any other referrals to or contact with social services
 Any social services involvement with siblings
LEA
 Attends a PRU or a school for children with education and behaviour difficulties
 Received a fixed term exclusion in the past 12 months
 Truanting at least 2-3 days per month in the past 12 months
 Permanently excluded in the past 12 months
Police
 Has received a reprimand or final warning
 Has been arrested in the past 12 months
 Has been convicted in the past 12 months and received a community sentence.
 Other contact such as persistent juvenile nuisance/ASBO in past 12 months
Schools – The young person has been:
 Permanently excluded in the past 12 months
 Received a fixed term exclusion in the past 12 months
 Truanting at least 2-3 days per month in the past 12 months
Other – The young person has been:
 Causing a nuisance in the YIP area
 Known to be offending but not in the youth justice system
 Involved with a negative peer group
 Siblings or other family members involved in offending

Signed:…………………………………… Name:…………………………………………. Date:………………
Are parent/carer aware of the referral? YES NO
PARENT/CARERS COMMENT ON REFERRAL

                                                                          PARENT/CARER’S SIGNATURE ………………………………………….


 Level of risk              High / Medium / Low

				
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