REFERRAL FORM

REFERRAL FORM

Wild AP | A Division of Wildlings Group Ltd
Student Information
Student name*

First NameLast Name
Their date of birth*

DayMonthYear
Date
Current age*
School Year*
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Carer name*

First NameLast Name
Parent/Carer email*
example@example.com
Parent/Carer phone*
Please enter a valid phone number.Format: 00000 000000.
Other emergency names & numbers*
Emergency protocol*
Referral reasons*
Situation prior to Referral*
Educational Information
If Other, please explain
Total number of schools attended
Last school
Reason for leaving last school
Permanently excluded?
If yes, please give more information around why.
Educational Status

On-roll at school and attendingOn-roll at school, not attendingEHE (Electively Home Educating)EOTAS (Education Other Than At School)Other
In receipt of Free School Meals?

YesNo
Special Educational Needs and Disabilities (SEND)?*
Exam grades (if applicable)
Other qualifications and achievements
Include dates achieved.
Functional skills
Previous Work Experience
Please add dates and contacts
Permission to contact Work Experience placements?

YesNo
Medical and Therapeutic Support*
Please tell us more about what kinds of support that have been received, any effects and progress as a result of the support. Please provide contact details of providers of support.
Permission to contact medical and therapeutic support providers?*

YesNo
Education*
Please give any further information you feel is useful to share. Contact details can be added here to any relevant professionals.
Educational support services? Please select any that apply.

Behaviour support serviceEducation welfareCareers guidanceLearning support serviceEducational psychologist / SENOther
Permission to contact above Providers?

YesNo
Social Services
If the young person has involvement, please give more details in the following questions. If relevant, please add contact names and details here.
Has the young person ever been 'Looked After'?*

NoSubject to Care OrderVoluntarily AccomodatedCare LeaverOther
Have they ever been on the Child Protection register?*

YesNo
General Health
Registered with GP?*
If so, please give contact details
Registered with Dentist?*
If so, please give contact details
Current medication
Allergies?
If yes, please state
Chronic conditions
Asthma, epilepsy, diabetes, skin conditions, etc.
Toilet Trained?*

YesNo
If not toilet trained, please describe continence issues and assistance requirements. What are the longterm goals?
Sleep patterns and/or disturbances?
Physical health issues?
If yes, please give details with any medical diagnoses
Mental health issues?
If yes, please give details with any medical diagnoses
Smoking
Do they smoke cigarettes, vapes or other substances? If so, how many per day?
Known conditions
Background history*
Learning styles
EHCP?*
If yes, please email details separately
Passions?
What do they love doing, or are passionate about?
Triggers?
Common situations that have led to problems in the past
Adaptations?
What can we do to help accomodate any of the above points?
Offending

Please let us know here of any details around any offences committed. Also add any contact details to relevant professionals here.
Have they been involved with the Police?*

YesNo
Offences: please select any that apply

Police (arrested)Police (informal)Police (reprimand)Youth engagement servicesYouth offending teamOther
Name of YOT Worker
Include contact details
Permission to Contact Worker?

YesNo
Age at first involvement
Age at last involvement
Types of offences in the last 12 months: select all that apply

Anti-social behaviourPhysical assultRobberyBurglaryMonetary theftMotoring offencesDrugs possessionTheftProperty damagePublic disorderSexual assultOther
If 'Other', please state
Outcome of last offence

Pre court orderCourt appearanceNothing
Pre court order type

No further actionCautionReprimandFinal WarningAnti social behaviourOther
Court outcome
Order/outcome
Number of convictions in the last year
Number of pending court hearings
Is The Young Person A Schedule 1 Offender?
Are They A Risk To Children?
Referrer Details
Name of person filling out this form*

First NameLast Name
Relationship to young person*
Your email (if differs from parent/carer)
example@example.com
Your phone number (if differs from parent/carer)
Please enter a valid phone number.Format: 00000 000000.
Address (if differs from parent/carer)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other information*
Is there any other information that we need to know about in relation to this referral?
Parental Contact: with reference to this referral, if it is via a professional or carer, have the parents been contacted about it?*

YesNoParent/Carer is making this referral
Referral Agency*
Funding source*
Please outline funding source: family, school, county, other. Please specify details.
Funding approved?*

Approved with access to fundsApproved but no access to funds yetFunding not yet approvedPrivately fundedOther
Maximum Hours Of Funding?*
Local Authority*
Where did you hear about us?*
Ideal start date?*
- Wild AP requires a payment in advance for an initial 1 hour assessment.
- This can be held at the home of the student, school, or on site at Wild AP for a private meeting.
- This assessment is to establish need and whether Wild AP can meet that need with the facilities we have access to.
- This meeting is no guarantee of provision with Wild AP, though we try not to turn away students and find ways to meet need wherever possible.
By signing below, I accept these points.
Signature of Referrer*
Today's date*

DayMonthYear
Date
Hour MinutesAM/PM Option
In receipt of Pupil Premium?

YesNo
Should be Empty:

REFERRAL FORM

Student Information

Educational Information

General Health

Offending

Referrer Details