Date of Referral: _______/_______/_______ Name of Referring Agency: _________________________________________ Address: _________________________________________ _________________________________________ _________________________________________ Name of Referring Contact: _________________________________________ Position Within Organisation: _________________________________________ Telephone Number/s: Work:____________________________________ Mobile:___________________________________ E-mail Address: _________________________________________
This form is to be used by professionals seeking to refer a young person to the Full Circle EducationTraining Programme. We offer a structured three day a week provision with alternative accreditationopportunities. A funding commitment MUST be agreed between the referring agency and Full CircleEducation, and this will be discussed once the referral has been agreed in principle.See our website
www.fullcircleeducation.com
for more information about our programme.
Referring Agency Details
Name of Young Person: _________________________________________ Gender: Male ( ) Female ( )Name of Parent / Guardian: _________________________________________ Address: _________________________________________ _________________________________________ _________________________________________ Home Telephone Number: _________________________________________ Mobile Telephone Number: _________________________________________ Date of Birth: ———/———/———- Age:_______________ Academic Year Group: Year 10 ( ) Year 11 ( )Is the young person eligiblefor free school dinners? Yes ( ) No ( )
Young Person Details
Why are you referring this young person to ‘Full Circle Education’?
Please tick all that apply in each section, and provide ALL additional and relevant informa-tion either: A. In the box provided below each section OR B. As attached documents from the young person’s filePlease expand and give any additional and relevant information about the young personhere:
Referral Information (1)
1. Known or suspected involvement in anti-social behaviour ( )2. Has been arrested (please provide details) ( )3. Substance abuse (alcohol, drugs etc.) ( )4. Friends, siblings or family in trouble with the police ( )5. History of violence/ abuse in the family ( )6. Problems at home ( )7. Problems with health (mental, emotional, physical) ( )8. Young Person is on the Child Protection Register ( )9. Other ______________________________________________________ ( )1. At Risk of Temporary/ Permanent Exclusion ( )2. Has already been temporarily excluded (Please provide details) ( )3. Persistent disruptive behaviour in the classroom ( )4. Failure to follow instructions ( )5. Rudeness and abuse towards staff and others ( )6. Not entered for GCSE’s ( )7. Moderate Learning Difficulties ( )8. Low Level Literacy/Numeric ( )9. Statemented ( )10. Non-attendance to school ( )11. School Phobic ( )12. Regular Truancy ( )13. Other Reasons:_____________________________________________ ( )
School FactorsSocial/ Family/ External Factors
Please expand and give any additional and relevant information about the young personhere:
How long and in what capacity have you known this young person?Referral Information (2)
Is the young person being referred currently on any other alternativeprogrammes or schemes?Full Circle Education only offers a three-day a week training programmeon Monday, Wednesdays and Fridays. What educational provision will bemade for the young person on the Tuesdays and Thursdays?
School : Negotiated Timetable ( )Home Study ( ) Alternative Training ( )Work Experience ( )Other ( )
Will the young person being referred be entered for any qualifications(e.g. GCSE, GNVQ, BTEC)?
Yes ( ) No ( )If Yes, please indicate below those which he/she will be entered for:
Please enter any other relevant information about the young person in-cluding their:
A. Strengths & AchievementsB. SkillsC. Specialist InterestsD. Additional Needs & Specific Requirements
of 00
Full Circle Referral Form
681 Reads
Info and Rating
| Category: | |
| Rating: | |
| Upload Date: | 07/22/2009 |
| Copyright: | Attribution Non-commercial |
| Tags: |
Leave a Comment