Referring Agency

Referring agency

Name of organisation:

Referral date:

Contact name:

Job title:

Address:

Post code:

Email address:

Phone:

Client information

Name:

NI number:

Address:

Post code:

Email address:

Phone:

Date of birth:

Age at referral:

School leaving date/year:

Living arrangements:

Living with parents/relative

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Own tenancy

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Other*

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Supported accommodation

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Temporaryaccommodation

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*Please specify

Reason for referral(please also complete the options sheet with client)

Issues to be taken into account

ADD/ADHD

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Dyspraxia

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Low school attendance

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Anxiety

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Health condition*

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Mental health

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ASD/Asperger’s

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Homeless/first time tenant

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Parent

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Communication difficulties

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Integration Team involvement

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Self-travel

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Disengaged from school

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LAAC/LAC

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Supervision order

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Dyscalculia

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Learning difficulty*

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Young carer

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Dyslexia

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Learning disability*

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Other*

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*Please specify

Education / Training / Employment (where known)

School(s) / college(s) attended:

School attendance percentage:

%

Education / Training / Employment (where known) cont…..

Qualifications gained (tick all that apply):

Access/National 3

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Intermediate 2

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Int 1 Group Award*

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Standard Grade

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Higher

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Int 2 Group Award*

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National 4

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NC*

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Princes Trust

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National 5

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HNC*

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National Units

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Intermediate 1

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ASDAN

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Other*

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*Please specify

Did the client receive any Additional Support for Learning / Base Support whilst at school / college?

Yes*

☐

No

☐

*Please specify:

Since leaving education, has the client engaged with further training, employment or volunteering opportunities?

Yes*

☐

No

☐

*Please specify:

Agencies / Support currently in place

Does the client currently receive support from any other agencies?

Yes*

☐

No

☐

*Please specify:

Other agencies / programmes referred to

Activity Agreement

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Employability Fund

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Princes Trust

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Barnardos Works

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Four Square

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Rathbone / XCEED

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CAMHS

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Homelessness Prevention

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SDS

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Changes

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Ingeus / A4E

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Tenancy Support

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Changeworks

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MELD

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TWO Programme

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ELVOS

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MYPAS

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Other*

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*Please specify

Additional information

Signature and consent

Has client given their consent to this referral?

Yes

☐

No

☐

Client’s signature:

Date:

Please complete the Options sheet with the client and include with this referral.

What do you want to work on at the moment?

Please circle all areas you would like to work on