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Referral Form

Home
About
Services
Organisations
Partners in Possibility
Contact
Blog
Referral Form

Referral Form

For young people aged 16 to 24 and their families

Let’s find a way forward, together. Provide the details below to refer a young person to our pathway programmes.

Referral Form

Referring Organisation *

Referrer Name *

Job Title *

Email Address *

Telephone Number *

Date of Referral *

Relationship to Young Person *

Full Name *

Preferred Name *

Date of Birth *

Age *

Home Address *

Young Person Contact Number *

Parent/Carer Name(s) *

Parent/Carer Contact Number(s) *

Parent/Carer Email *

Emergency Contact Name *

Emergency Contact Number *

Current School / College / Provision *

Current Year Group / Programme *

Is the young person currently attending? * Yes No

If no, please explain *

Current attendance percentage (if known) *

Is the young person: * At risk of NEET Currently NEET Educated at home (EHE) Excluded or at risk of exclusion Seeking employment Seeking supported internship placement

Does the young person have an EHCP? * Yes No

Primary Need *

Additional Needs / Diagnoses * Autism SEMH ADHD Anxiety EBSA Learning Difficulties Speech and Language Needs Trauma / ACEs Other

If other, please specify:

Please provide a brief overview of need *

Are there any safeguarding concerns? * Yes No

If yes, please provide details

Is the young person currently open to * Social Care Early Help CAMHS Youth Offending Service Family Support Adult Services Other

If other, please specify:

Known risks (tick if applicable) * Absconding Aggression Self harm Suicidal ideation Substance misuse Exploitation risk Criminal exploitation Sexual exploitation Online safety concerns Unsafe behaviours in the community None known

Risk management strategies currently in place

Medical conditions / diagnoses *

Medication requirements *

Allergies / dietary requirements *

Mental health support currently involved *

What are the main barriers affecting this young person currently? *

What support are you seeking from Beyond Barriers CIC? * Re-engagement with education SEMH support Employability support Supported internship Functional skills support Life skills / independence Community engagement Mentoring Short term intervention programme Transition support Other

If other, please specify:

Desired outcomes for this placement

Has the young person completed any work experience previously? Yes No

Areas of interest / career aspirations

Any known barriers to employment

Which documents are you including? EHCP Latest Annual Review Risk Assessment Behaviour Support Plan Attendance Information Safeguarding Information Professional Reports Timetable Other relevant documentation

I confirm the above statement and consent to my data being processed for this purpose * I agree

Let us find a way forward, together

Whether you are commissioning provision, referring a young person, or looking for support for your family, we are here.

Refer a young person

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