SHIFT REFERRAL FORM

  • SHIFT REFERRAL FORM

    Please complete all questions within each section dropdown.

  • Consent

    Verbal consent must be obtained from the young person before this referral is made.

    If the young person is under 16, signed consent from their parent/carer must also be obtained. If you have emailed the consent form link to the parent/carer, please wait until you receive notification that it has been signed before completing this referral. The autonotification will come from a Jotform email address.

    If the young person is 16 or over, then their parent/carer must be notified that the referral is being made, but consent is not required.

    If you have any questions please contact: aisling@audioactive.org.uk and cc ellie@audioactive.org.uk (for Brighton & Hove and East Sussex) or jo@audioactive.org.uk (for West Sussex)

  • I have gained verbal consent from the young person to make this referral*
  • The young person is aged 11-15 and I have gained signed parent/carer consent to make this referral*
  • How have you gained signed parent/carer consent?
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  • The young person is aged 16-17 and I have informed the parent/carer about the referral*
    • Eligibility 

    • Eligibility criteria

      To be eligible for SHIFT, the young person must be 11-17 and have one or more yes ticks in sections a), b) or c)
    • Young person is 11-17 years old*

    • It looks like the young person you're referring might not be eligible for SHIFT. 

      If you think you've received this message in error or have any further questions please contact aisling@audioactive.org.uk (please also cc tom@audioactive.org.uk and jo@audioactive.co.uk) before completing the rest of the form.

    • a) The young person has been convicted of a criminal offence*
    • b) The young person has been arrested, but has not received a criminal conviction*
    • c) Considered at high/medium risk of offending due to demonstrating one or more of the following factors (tick all that apply)*

    • Ineligibility criteria

      Must tick no for the ineligibility criteria listed at a), b) and c) to be eligible for SHIFT
    • a) The young person is currently serving a custodial sentence*
    • b) The young person has previously received multiple custodial sentences*

    • It looks like the young person you're referring might not be eligible for SHIFT. 

      If you think you've received this message in error or have any further questions please contact aisling@audioactive.org.uk (please also cc tom@audioactive.org.uk and jo@audioactive.co.uk) before completing the rest of the form.

    • c) The young person is currently accessing a music mentoring or similar arts-based mentoring intervention*

    • We'll need to know more details about the music/arts intervention in order to determine the young person's eligibility for SHIFT. 

      Please contact aisling@audioactive.org.uk (please also cc tom@audioactive.org.uk and jo@audioactive.co.uk) to let us know these details, so we can advise on eligibility before you complete the rest of the form.

    • Referrer information 
    • Format: 00000-000000.
    • Referral organisation type*

    • A note on the broad organisation types. 

      Schools includes all primary, secondary.
      ***PRUs, Virtual Schools and Colleges are Other.

      Social Care includes statutory services funded by the local authority; such as Early Help, Children's and Adolescent Services, Children's Homes etc.

      Youth Justice Services inlcudes the Police, Probation, Youth Offending Teams etc.

      Voluntary Sector includes organisations that are a charity or CIC etc. 

      Other includes local authority services such as YES, orgs not covered above, parent referrers etc

    • Date referral completed*
       / /
    • Young person's details 
    • Date of birth*
       / /
    • Format: 00000-000000.
    • Where young person lives (or goes to school)*
    • SEND status*
    • SEND needs*
    • Education, Health and Care Plan status (EHCP)*
    • Any access requirements?*
    • Communication and language needs?*
    • Social care status*
    • Current Social Worker?*
    • Historical social care status (choose highest level of intervention)*
    • Other current service involvement*
    • Pupil Premium / Free school meals eligibility*
    • English as a Second or Other Language*
    • Current education, training or employment placement*

    • Vulnerability factors

    • Familial*
    • Health and Wellbeing*
    • School*
    • Peer relationships*
    • Financial*
    • Victimisation (where the young person has felt harmed)*
    • Equality, Diversity and Inclusion (young person) 
    • Young person's preferred pronouns*
    • Gender identity*
    • Sex assigned at birth*
    • Sexuality*
    • Parent/guardian details 
    • Format: 00000-000000.
    • Is the parent/guardian's home address different to that of the young person?*
    • Thank you for completing the form - please press submit below 

    • AudioActive is committed to upholding data protection laws and the privacy rights of individuals. Please read our privacy notice for more details about your rights, and how and why we process the data we receive from you.
      By clicking submit, you agree that AudioActive can process the data provided.

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