Referral Form
Stable Futures, part of Amegreen Children's Services, provides equine, education, therapy and training programmes for young people who are not accessing mainstream education. Please complete as much of this form as you can. If you are unsure about any section, leave it blank and we will follow up with you.
Referrers Details
Please enter your contact details so we can reach you to discuss your application:
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
Street Address
Street Address Line 2
Town / City
Post Code
County
Referral Date
-
Day
-
Month
Year
Date
Requested Start Date
-
Day
-
Month
Year
Date
Is there parental contact?
Yes
No
Other
Referral Agency
Referral Reasons
Please give us as much background information as possible about the learners current circumstances:
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Learners Details
Please provide the information below to be able to probably assess your application:
Learners Name
First Name
Last Name
Learners Date of Birth
-
Month
-
Day
Year
Date
Learners Gender
Male
Female
Other
Learners Current Address
Street Address
Street Address Line 2
Town / City
Post Code
County
Learners Contact Number
-
Area Code
Phone Number
Emergency Contact Name
First Name
Last Name
Emergency Contacts Relationship to Learner
Emergency Contacts Address
Street Address
Street Address Line 2
Town / City
Post Code
County
Learners Ethnicity
Learners Religion (in none please write 'none')
Does the learner have challenges with any of the following? (please tick all that apply):
Reading
Writing
Language / Speaking
Listening
Talking in front of others
Numeracy
Focus and concentration
Working in a group / team
Does the learner have the following? (please tick all that apply)
Safe and stable accommodation?
Access to a stable supply of healthy food?
Suitable and clean clothing for various activities and weathers?
Other
Please provide any further information that would be useful ie: diagnosis, health issues / need etc)
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Learners Education Information
Please provide information about the learners current and past education history
Total number of schools attended:
Name and location of last school:
Reason for leaving last school:
Was the learner permenantly excluded and if so why?
Please provide any other information or comments with regards to the learners education history, any learning difficulties or support requirements:
GCSE results or any other grades applicable:
Has the learner achieved any other qualifications, if so please list below with dates of when achieved:
Functional Skill Level in English
Please Select
Very poor
Poor
Average
Good
Very Good
Excellent
Functional Skill Level in Maths
Please Select
Very poor
Poor
Average
Good
Very Good
Excellent
Has the learner ever had any work experience? if so please give details of the role, responsibilities and dates as well as reason for leaving:
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Agency Involvement
Please provide information on any agencies or social services that are currently involved with the learner:
Social Services:
Family social worker
Own social worker
Housing association
Other
Name of Social Worker
Permission to contact?
Yes
No
Permission to contact?
Yes
No
Permission to contact?
Yes
No
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Offending & Criminal Behaviour
Please provide the necessary information about the learners offending behaviour, if the learner has had no criminal involvement please skip to the next section:
Offending
Police (arrested)
Police (informal)
Police (reprimand)
Youth engagement service
Youth offending team
Other
Name of YOS / YOT worker
Permission to contact?
Yes
No
Has the learner been 'looked after'?
Please Select
No
Subject to care order
Voluntarily accommodated
Care leaver
Has the learner been on the Child Protection register?
Yes
No
Other
Age at first involvement
Age at last involvement
Outcome of last offence
Please Select
Pre court order
Court appearance
None
Pre Court Order Type
Please Select
No further action
Caution
Reprimand
Final warning
Anti social behaviour order
Other
Court Outcome
Please upload copy or order / programme
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Number of convictions in the last year?
Number of pending court hearings?
Is the learner a Schedule 1 offender?
Yes
No
Is the learner a risk to other children?
Yes
No
Other
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Health
Please provide details of the learners health and wellbeing
Please provide details of their registered GP address
Practice Name
Pracitce Address
Town / City
Post Code
County
Name of GP if known
First Name
Last Name
GP Practice Contact Number
-
Area Code
Phone Number
Is the learner under any current medication? if yes please give details below
Yes
No
Unknown
Details of current medication
Does the learner have any allergies? if yes please state details below and treatment
Does the learner have any chronic conditions such as asthma, epilepsy, diabetes, skin conditions etc? (if you answered yes please give details below)
Yes
No
Please provide details and treatment for any current chronic conditions of the learner
Does the learner smoke? If you answer yes please fill in how many day below
Yes
No
Unknown
If you answered yes, please state on average how many cigarettes the learner smokes per day
Would you like support in reducing or stopping any of the above?
Yes
No
Other
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Learner Profile
Name
First Name
Last Name
Age
Class
Known Conditions
Background History
Learning Style
Positives (what do they enjoy, or have a special skill or interest in?)
Triggers (what situations or problems have triggered them in the past?)
Submit
Should be Empty: