Refer a young person
Use this from to tell us about the young person you wish to be considered for intervention by the Oxygen Team. The data on this form will be encrypted and stored in compliance with GDPR. You can visit our web site for more information on our services: www.oxygen-online.org
Your Name (person making the referral)
Do you give consent for the information you provide on this form to be held by Oxygen for the purpose of providing support to the young person named below?
Please type "yes" into the box
Name of organisation
School or college
Statutory service provider
Your role and relationship with the young person
Name of young person
How old is the young person?
Date of birth
Street Address Line 2
State / Province
Postal / Zip Code
Asian or Asian British (Includes any Asian background, for example, Bangladeshi, Chinese, Indian, Pakistani)
Black, African, Black British or Caribbean (Includes any Black background)
Mixed or multiple ethnic groups (Includes any Mixed background)
White (Includes any White background)
Another ethnic group
Prefer not to say
Current place of education:
School / college/ specialist provision
Borough or Local Authority area in which they live
Kingston Upon Thames
Richmond upon Thames
Other London Borough
Epsom and Ewell
Parent/ guardian's name & contact details
What is the best way to initiate contact with the young person (Phone, email, text, through you, school, parent/guardian). Please note that direct contact with a young person outside a school setting will require the consent of a parent or guardian. This can be given through completing Oxygen's Youth Engagement Consent Form here: https://forms.gle/GaXQmK9v92PZc5NZ6
Please indicate the level of risk you feel the young person presents to themselves or others:
Is the young person subject to any referral to the local authority on the basis of safeguarding concerns
I don't know
We may ask you to tell us more before meeting the young person.
What is your main concern for the young person
Does the young person have a special educational need or disability?
If they do then please give details.
Please tell us about any interests, strengths or hobbies the young person might have:
This information will help us to identify the most suitable member of the Oxygen team to engage with the young person.
Please briefly describe the nature of the young person's needs
Are there any risk factors which we need to be aware of to ensure Oxygen's staff and volunteers are protected?
What types of intervention do you feel would best meet the young person's needs?
Mentoring or coaching
Applying for education or training
attendance at a local youth project
Volunteering in the Oxygen Shop
Is there any other or additional information which you think might be helpful to us.
Thank you for completing the form
A member of the Oxygen Team will be in touch soon. If you wish to contact the team then please email email@example.com or call our office on 0208 547 0566. Visit the Oxygen web site www.oxygen-online.org
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm