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 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*

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
- 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*
  
  YesNo
- 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*
  
  YesNoNot known
- Brief details of conviction
- b) The young person has been arrested, but has not received a criminal conviction*
  
  YesNoNot known
- Brief details of arrest
- c) Considered at high/medium risk of offending due to demonstrating one or more of the following factors (tick all that apply)*
  
  Excluded, or at risk of exclusion (ie through persistent absences and suspension) from mainstream education due to displaying behaviours including offending, bullying, aggression, violenceDrug use or possessionKnown association with high-risk peers known to be involved in criminal activityKnown to have siblings already involved in criminal activitySigns of possible criminal exploitation - eg burner phones, unexplained change in finances, going missingDisplaying overt coercive or violent behaviourCarrying weapons such as knivesNone of the above
- Details of risk factors
- 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*
  
  YesNo
- b) The young person has previously received multiple custodial sentences*
  
  YesNo
- 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*
  
  YesNo
- 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 name*
  
  First NameLast Name
- Referrer email*
- Referrer contact number*
- Role of referrer*
- Name of referral organisation *
- Referral organisation type*
  
  SchoolSocial CareYouth Justice ServicesVoluntary SectorOther
- 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*
  
  DayMonthYear
  Date
- Date of birth*
  
  DayMonthYear
  Date
- Young person's email address
  If they're over 16 and have their own email address
- Young person's phone number
  If known, and you think it would be useful for practitioners to be able to contact YP directly for session reminders etc
- Young person's home address*
  
  Address
  
  Address Line 2
  
  City or townCounty
  
  Postcode
- Where young person lives (or goes to school)*
  
  Brighton & HoveEast SussexWest Sussex
- East Sussex District
- West Sussex District
- SEND status*
  
  Recorded SENDNo recorded SENDNot known
- SEND needs*
  
  Cognition and learning: Specific Learning DifficultyCognition and learning: Moderate Learning DifficultyCognition and learning: Severe Learning DifficultyCognition and learning: Profound and/or Multiple Learning DifficultiesCommunication and interaction: Speech, Language and/or Communication DifficultiesCommunication and interaction: Autistic Spectrum ConditionSensory impairment: Hearing ImpairmantSensory impairment: Vision ImpairmentSensory impairment: Multi-sensory ImpairmentPhysical disabilitySocial Emotional and/or Mental Health DifficultyNot knownNoneOther
- Education, Health and Care Plan status (EHCP)*
  
  YesNoNot known
- Any access requirements?*
  
  YesNoNot known
- Please describe access requirements
- Communication and language needs?*
  
  YesNoNot known
- Please describe communication and language needs
- Social care status*
  
  NoneChild in Need (CIN)Child of a Child Protection Plan (CPP)Child Looked After (CLA)Not known
- Current Social Worker?*
  
  YesNoNot known
- Social Worker name (if known)
  
  First NameLast Name
- Social Worker email (if known)
- Historical social care status (choose highest level of intervention)*
  
  NonePreviously Child in Need (CIN)Previously child on a Child Protection Plan (CPP)Previously Child Looked After (CLA)Not known
- Other current service involvement*
  
  Children's ServicesCAMHSEarly HelpYouth Justice ServicesSubstance Misuse ServicesISENDEmployment SupportVoluntary SectorNoneNot knownOther
- Pupil Premium / Free school meals eligibility*
  
  YesNoNot known
- English as a Second or Other Language*
  
  YesNoNot known
- Current education, training or employment placement*
  
  SchoolTrainingEmploymentAlternative provisionEducation other than at school (EOTAS)Not in education, employment or training (NEET)Not known
- Name of school / facility (if known)
- Vulnerability factors
- Familial*
  
  Concerning situationHousehold substance misuse, domestic abuse, mental healthPoor family relationshipsParental separation / divorceRelative in prisonNot knownNoneOther
- Health and Wellbeing*
  
  Drug misuseAlcohol misuseMental health / wellbeing needPhysical needNot knownNoneOther
- School*
  
  Low educational attainmentPersistent absenteeismExclusionBullyingNot knownNoneOther
- Peer relationships*
  
  Poor peer relationshipsAssociation with inappropriate peer groupsHarmful sexual behavioursNot knownNoneOther
- Financial*
  
  PovertyHousing needNot knownNoneOther
- Victimisation (where the young person has felt harmed)*
  
  Previous victim of crimeRacismHomophobiaTransphobiaNot knownOther
- Please give the reasons for your referral with any relevant additional context about the young person's risk and vulnerability factors*
- Any other information relevant to the referral*
  Please include details of the best dates/times that we'll be able to meet this young person
- Young person's preferred pronouns*
  
  He/HimShe/HerThey/ThemNot knownPrefer not to sayOther
- Gender identity*
  
  FemaleMaleNon-BinaryTransPrefer not to sayOther
- Sex assigned at birth*
  
  FemaleMaleNot knownPrefer not to say
- Sexuality*
  
  HeterosexualGay / LesbianBisexualNot knownPrefer not to sayOther
- Ethnicity*
- 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
- 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.
- Should be Empty:

SHIFT REFERRAL FORM

Consent

Eligibility criteria

Ineligibility criteria

Vulnerability factors