Refer a young person

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)*

First Name Last Name
Email*
example@example.com
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
Phone Number*

Area Code Phone Number
Name of organisation*
Organisation type
Your role and relationship with the young person
Name of young person*

First Name Last Name
How old is the young person?
Date of birth

DayMonth Year
Date
Gender of young person
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Ethnicity
Current place of education:*
School / college/ specialist provision
Borough or Local Authority area in which they live
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
We may ask you to tell us more before meeting the young person.
Is the young person a Looked After Child?
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 coachingHeadstart Action programmeApplying for education or trainingWork experienceup-cycling projectattendance at a local youth projectIntensive interventionVolunteering 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 info@oxygen-online.org or call our office on 0208 547 0566. Visit the Oxygen web site www.oxygen-online.org
Should be Empty:

Refer a young person

Thank you for completing the form