Referral Form

Field of Joy

Catchback Lane, Reepham, Norwich

Parking/Meeting Point: Reepham Tennis Courts, Kerdiston Road, Reepham, NR10 4LQ

fieldofjoynorfolk@gmail.com

www.fieldofjoy.org

(44) 7923015659
Referral Form

** Please only submit once funding is confirmed and in place
Learner Details:
Full Name

First NameLast Name
Preferred Name

First NameLast Name
Gender/Identifies as
Ethnic Origin
Religion
Date of Birth

MonthDayYear
Date
School Name or Commissioner
Year Group
ULN Number
% attendance at time of referral
Further details of any persistent absence issues:
School Key Contact Name and Role
School Key Contact Phone Number

Area CodePhone Number
School Key Contact Email
example@example.com
School DSL Name
School DSL Contact Phone Number

Area CodePhone Number
School DSL Contact Email
example@example.com
Please tick if the Learner is subject to any of the following:
Details of Social Worker (if applicable)
Details if English is an additional language for the Leaner?
Details of any other agencies involved with the Learner:
Details if the Learner attends or has previously attended any other Alternative Provisions:
Details of any behavioural issues and or exclusions:
Please provide any relevant information relating to the following: Identity, Religious, cultural, and ethnic background.
Please provide any relevant information relating to the following: Any specific learning difficulties/social/emotional/mental health needs or behavioural difficulties (dysregulated, ODDetc) diagnosed or not.
Type of Home Placement (Family Home, Foster Home, Residential Care etc)
Reason why young person is in care or accommodated (If applicable):
Are there any issues or vulnerabilities at home that we should be aware of?
If other, please give details:
Name(s) of person(s) at home or placement that have responsibility for the young person, plus relationship to young person. These should be who we would contact in an emergency (Two Contacts Please)
Addresses of Emergency Contacts
Emails of Emergency Contacts
Phone Numbers of Emergency Contacts
Persons to whom the young should not have any contact with?
Please detail of any and all concerning behaviours which would impact a Risk Assessment? Please ensure to attach an up-to-date risk assessment of the young person with this referral form.
Please state any risk the young person may present to him/herself, staff, other people, animals, the smallholding or public. Give as much detail as possible.
Does the young person require any assistance with toileting/personal care?
Does the young person take any prescribed medications? If so, what, why and what dose. Ensure to detail in care plan.
Does the young person require any emergency medications? If so, why, what, and when? If yes, attach the current Emergency Plan for the young person.
Is there already a Care Plan in place for this young person? If yes, please attach a copy.
Brief background and reason for referral, which is pertinent to the application.
Young Person’s Hobbies, interests, likes and talents:
Please attach relevant documents to this referral including EHCPs:

Cancelof
Initial Site Visit

Field of Joy recommends all learners and commissioning parties visit the woodland prior to the commission of a place.
Who should Field of Joy contact to arrange this visit?
Contact Phone Number

Area CodePhone Number
Email
example@example.com
Who do we contact if you are unavailable?
Placement to be funded by?
Please email Caitlin Howells at fieldofjoynorfolk@gmail.com to arrange a commissioning party visit.
Level of Provision:
What level of support does the young person require (adult:young person ratio)?
When would you require the service to commence?

MonthDayYear
Date
How long is the provision planned to last?
Areas of Need and Desired Outcomes
Please use the space below to list measurable outcomes and goals that you would like the young person to achieve while at Field of Joy.
Name of Referrer

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Referral Form

Areas of Need and Desired Outcomes