Referral Form for Dramatherapy

Croydon Early Intervention and Support Services and Tangled Feet are offering two 18 week dramatherapy groups for young carers aged 9-17 funded by Children in Need This will include a residential trip at the end of the project. There are also limited numbers of 8 or 10 week one to one dramatherapy sessions open to any young person who may benefit. Sessions will take place in Croydon (Norwood Junction) on a Monday after school. Please state which allocation your young person requires in the ‘reason for referral’ box

Please complete and return to:Jessica Hodge, Young People’s Specialist Programmes Coordinator, Croydon Council: by January 16th 2017

(Any questions please contact )

Young Persons Information *
Name * / Date of * birth
YP * Mobile / Age
Ethnicity / Gender
YP Email address / Religion
Address * / ______
______Postcode: ______
Currently (please tick as many that apply)
At school / At college
Doing volunteer work / On a training scheme
Employed / Carer
Unemployed / Looked after
If at school/college, please state name and address and contact details:
Does the young person have a learning difficulty/disability or any medical conditions?
Yes / No / If yes, please state :
Please outline needs of the young person:
Are all your vaccinations up to date? (Yes/No )
Is there any medication they will need to take whilst with us? * (Yes/No) Please tell us below:-
Allergies/Dietary requirements:
Do they have permission be filmed and photographed during the project? *
Yes / No / This will be used for evaluation purposes by Croydon Council & Tangled Feet.
Does this young person have permission to travel on their own around the borough?
Yes / No / This means to, from and during sessions.
Referee/Parent/Carer Info: * Please sign below to consent to us holding the information on this form.
Name * / Relationship *
Mobile no. * / Home no.
Email *
Signature
Emergency Contact 1 * (if different from above)
Name * / Relationship *
Mobile no. * / Home no.
Emergency Contact 2 * (different from above)
Name * / Relationship *
Mobile no. * / Home no.

For the following sections please give as much information as possible. Detail the child’s social, emotional, behavioural needs as well as any clinical diagnosis if applicable. Please continue on separate sheets if necessary.

Reason for referral – please state if this is a Young Carers Group or Individual Dramatherapy referral
Is the young person receiving any other agency / council support?
(If yes, please give details…e.g. social services)
Has the young person received any therapeutic support in the past? If yes please specify type and duration
What is the family and home situation of the young person?
Any significant events in the young person’s history?
Reason for referral – please state if this is a Young Carers Group or Individual Dramatherapy
How does the young person relate to others?
What are the young person’s likes / interests / hobbies?
What are the young person’s difficulties / fears?
Aims for Dramatherapy…
Other relevant information
(i.e. preferred behavioural strategies, etc.)
Parent/Carer signature and agreement
regarding information sharing / I understand that the Dramatherapy sessions are confidential and I agree that the Dramatherapist may share relevant information with other professionals.
Signed :
Date:
If parent/carer has not signed, please confirm parent/carer has given explicit consent for referral? / Name of referrer:
Signature to confirm consent has been given:
Date:
NB: Places are allocated on a first come first serve basis. We urge you to return the referral form promptly as these free sessions fill up very quickly. We will inform the referrer by the 31st of January and groups and individual sessions will commence on the 20th February. The groups will run for 18 weeks and individual sessions will be offered for 8 or 10 weeks.

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