Adult Referral Form
Name & Contact details of person being referred:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
Town
County
Postal Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Contact details of person completing the form:
Name
*
First Name
Last Name
Connection with person being referred:
*
Organisation name (if relevant):
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
A bit more about the person being referred (must be over 16 years old):
Which most accurately describes you:
*
Man
Woman
Non-binary
Prefer not to say
Other
If Other, please let us know:
How should we address you?
*
She/her
He/him
They/them
Prefer not to say
Other
If other, please let us know
Current Age:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Ethnicity:
*
Which school, college or other support services do you attend, or what do you do each day?
*
What was your attendance at school, college or support service in the last full term?(please give a percentage)
*
What hobbies/interests do you have?
*
What things don’t you like/upset you?
*
What are your current difficulties/concerns?
*
What do you hope to achieve by coming to Field of Joy?
*
Are there any animals you particularly like?
*
Are there any animals you are concerned/afraid of?
*
Health & Wellbeing
Please tick any which are relevant
Physical disability
Epilepsy
Mobility and/or Gross Motor issues
Personal care needs
Allergies
Heart condition
Reading/writing difficulties
Social/emotional difficulties
Visual impairment
Hearing impairment
Speech impairment
Behavioural issues
Barriers to learning
Learning Disability
Deaf
Autism
ADHD
Dyslexia
Dyspraxia
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits)
Auto-immune conditions such as systemic lupus erythematosis (SLE)
Organ specific, including respiratory conditions, such as asthma,and cardiovascular diseases, including thrombosis, stroke and heartdisease
Mental health conditions with symptoms such as anxiety, low mood, panic attacks, phobias, or unshared perceptions; eating disorders; bipolar affective disorders; obsessive compulsive disorders; personality disorders; post traumatic stress disorder, and some self-harming behaviour
Mental illnesses, such as depression and schizophrenia
Manual Dexterity
Perception of Physical Danger
Please provide further details on any of the above which have been ticked, including how they are managed/medicated and how they affect you on a day to day basis.
What are your support needs?
Do you have any access requirements you would like us to be aware of?
Do you currently receive 1:2:1 support from a Teacher Assistant (TA) or Personal Assistant (PA). If so, please explain the support received?
Please tick if you have any of the following and provide a copy
An EHCP (Education, Health and Care Plan)
A personal risk assessment
A child protection plan
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Which other organisation or agencies are involved with providing support and named professional contact details if appropriate
We advise that you ensure your Tetanus vaccinations are kept up to date. When were your last tetanus vaccinations?
*
Your placement preferences:
How will you be attending the session?
*
On your own
with a support worker/carer
How will you get to Field of Joy?
*
Bus
Private Car
Taxi
Other
If Other, please explain
How will sessions be funded?
*
EHCP
School
Local Authority
Direct payment
Private funding
Other
If Other, please explain
DECLARATION:By completing this form, you have confirmed that the information on this form is correct to the best of your knowledge and understand that the information contained in this form will be kept safe in the person’s personal file. The full privacy notice can be found on our website www.fieldofjoy.co.uk
Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Next Steps
We will contact you to discuss if we think a placement would be suitable and whether we have availability. We would then invite you (and a family member, carer or support worker) for a short visit to the Field of Joy so you can see where we are, what we get up to and discuss the potential placement. There will then be a trial sessionoffered if appropriate.Our Designated Safeguarding Lead is Caitlin Howells.If you wish to discuss this referral request or want help filling in the form please email fieldofjoynorfolk@gmail.com and we will be pleased to help.
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