SW!TCH Referral Form

SW!TCH Referral Form
I am filling this referral form in as a*
Young Person
Before we proceed, please take a moment to review the following statement and indicate your consent by ticking the box below.

I understand that by providing my explicit consent, I allow LifeLine Projects to collect and process my child's personal data for the purpose of providing my child with mentoring support.

I acknowledge that I have reviewed the SW!TCH Privacy Notice and agree to its terms.
I agree to the collection and processing of my child's data.I agree to the SW!TCH Privacy Notice.
Before we proceed, please take a moment to review the following statement and indicate your consent by ticking the boxes below.

Data consent: I confirm I have the relevant consent of the legal parent/guardian or young person to share the information in this referral form with LifeLine Projects.

I acknowledge that I have reviewed the SW!TCH Privacy Notice and agree to its terms.
I confirm I have the relevant consent.I agree to the SW!TCH Privacy Notice.

1. Referrer’s Details
Name of Referring Agency *
Referrer’s Email Address*
example@example.com
First Name of Referrer*
Surname of Referrer*
Referrer’s Contact Number*
Please enter a valid phone number.Format: 00000000000.

2. Young Person’s Details
First Name *
Surname*
Date of birth*

DayMonthYear
Date
Young Persons Phone Number.*
Please enter a valid phone number. If unknown please fill in with eleven 0's.Format: 00000000000.
Ethnicity*
MaleFemaleNon-BinaryOtherPrefer Not to Say
Type of education attending*
School Attending*
Year Group*
Year Group (DNU)*
Address*

Street Address

Street Address Line 2

CityBorough

Postal Code
Borough*
Parent/Legal Guardian First Name *
Parent/Legal Guardian Surname*
Parent/Legal Guardian's Email Address*
example@example.com
Parent/Legal Guardian's Phone Number*
Please enter a valid phone number.Format: 00000000000.

3. Assessment of Young Person at Referral

Please indicate which type of mentoring you are referring the young person for. Please note that this is an opportunity to express a preference, but LCP retains the right to offer a space depending on assessment criteria and availability.
1:1 mentoring referralSchool small groupCommunity 1-1
1:1 mentoring referralSchool small groupCommunity 1-1
Reason (include any risks or barriers assessors should be aware of when assessing and assigning mentoring places) *

Additional School referral information (complete only if applicable)

Attendance Previous Term
Attendance %*
Authorised Absence %*
Unauthorised Absence %*
Attendance Notes
Behaviour

Behaviour during previous term
Detentions*
Reports*
Inclusion/Respite Days*
Fixed term exclusion days *
Behaviour Notes
Inclusion Unit Days

5. Other Agency Involvement
Are other agencies working with this young person?*
If yes, please give details of the agency together with a contact name and number if known.(examples: Course/Programme Tutor, Housing, Police, Youth Offending Service, Voluntary Sector, Mental Health, Educational Welfare, Learning Mentor, Benefits Agency, Social Services and Youth Organisations).
OwnerId
Should be Empty:

1. Referrer’s Details