SHIFT REFERRAL FORM

SHIFT REFERRAL FORM

Please complete all questions within each section dropdown.
Name of the young person being referred*

Young person's first nameYoung person's last name
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 tom@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*

YesNoN/A
The young person is aged 11-15 and I have gained signed parent/carer consent to make this referral*

YesNoN/A
How have you gained signed parent/carer consent?

Received notification of signature submission via emailI have a scanned paper copy
Signed consent scan upload

Cancelof
The young person is aged 16-17 and I have informed the parent/carer about the referral*

YesNoN/A

Referrer information
Referrer name*

First NameLast Name
Referrer email*
Referrer contact number*
Role of referrer*
Name of referral organisation *
Referral organisation type*

SchoolSocial careYouth Justice ServicesVoluntary SectorOther
Date referral completed*

DayMonthYear
Date

Parent/guardian details
Parent/guardian name*

First NameLast Name
Parent/guardian email address*
Parent/guardian phone number*
Is the parent/guardian's home address different to that of the young person?*

YesNo
Parent/guardian home address*

Address

Address Line 2

City or townCounty

Postcode

Thank you for completing the form - please press submit below
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Eligibility criteria