Welfare Referral

Welfare Referral

Once completed this form will be directed straight to Safeguarding/ welfare team: Safeguardingwelfare@debutacademy.com
Learners Name*

First NameLast Name
Cohort Class*

Funding type
Date*

DayMonthYear
Date
Reason for completing the welfare form:
- learner experiencing financial difficultie
- learner experiencing problems with their health or medical matters
- learner having difficulties with learning or study environment (at college or home)
- learner having issues with their accommodation
- learner who is struggling to get to college, low motivation, cannot afford fares
  equality & diversity
- issues circumstances changed at home regarding family/home life that is affecting them personally bereavement
- mental health (anxiety, panic attacks, low self-esteem, anger, mood swings, depression)
- drug & alcohol misuse
- carer responsibilities affecting them
- learner mentions they are having counselling
- learner indicating they do not feel safe coming to college or going home
- issues with learner placement or employer (apprentices and traineeships)
- changes in behaviour and personality or appearance
Concerns: What has been disclosed? Use TED - TELL EXPLAIN DESCRIBE. Please enter details such as date you were told about the welfare concern (was it from the person themselves or a third party), actual words that were disclosed (facts), how long the concern has been going on, who else may be involved with the welfare matter etc :*
Date of concern incident*

DayMonthYear
Date
Contact information of referred learner;
Email of referred person *
example@example.com
Phone Number*
Please enter a valid phone number.
NEXT OF KIN DETAILS of referral
Name

First NameLast Name
Relationship to person:
Email
example@example.com
Phone Number
Please enter a valid phone number.
Have you explained that the information given will be shared?*

YesNo
Staff Name referring learner*

First NameLast Name
Staff Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty: