Referral Form

1
1st Parent/Carer's Name * This field is required.
Prefix
First Name
Last Name
2
2nd Parent/Carer's Name* This field is required.
Prefix
First Name
Last Name
3
Name of Young Person* This field is required.
First Name
Last Name
4
Address* This field is required.
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Paren't Main Contact Number* This field is required.
Please enter a valid phone number.
6
Young Person's Gender* This field is required.
Please Select
Please Select
Male
Female
Transgender
Inter-Sex
Non-Binary
AGender
Gender Fluid
Gender Neutral
Genderqueer
Neutrois
Questioning
Other
Prefer to self describe
Prefer not to say
Not Provided
7
Young Person's Date of Birth* This field is required.
Date
Day
Month
Year
8
Young Person's Ethnicity* This field is required.
Please Select
Please Select
White - White English
White - White Northern Irish
White - White Welsh
White - White Scottish
White - White British
White - White Irish
White - White Eastern European
White - Other White Background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Black British
Mixed - White and Asian
Mixed - Other Mixed Background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Other Asian Background
Black or Black British - Black Caribbean
Black or Black British - Black African
Black or Black British - Black British
Black or Black British - Other Black Background
Other - Arab
Other - Gypsy/Romany/Irish Traveller
Other - Other Ethnic Group
Prefer Not To Say
Not Provided
9
Is An Interpreter Required? * This field is required.
YESNO
10
Family Composition* This field is required.(please include details of all other immediate family members to the referred including their name, age and relationship to the referred)
Huge
Large
Normal
Small
Ok
Ok
11
Does The Young Person Have Any Disability And/Or Special Needs? If Yes, Please Select From The Dropdown All That Apply
Please Select
Angelman Syndrome
Asperger's Syndrome
Attention Deficit Hyperactivity Disorder (ADHD)
Autism
Cerebral Palsy
Downs Syndrome
Dyslexia
Dyspraxia
Epilepsy
Global Development Delay
Hearing Impairment
Learning Difficulties: Moderate
Learning Difficulties: Severe
Sensory Processing Disorder
Spina Bifida
Tourette's Syndrome
Visual Impairment
Wheelchair User
12
Does The Young Person Currently Have Any Diagnosed Mental Health Conditions Or Have They Ever Been Diagnosed With A Mental Illness? If Yes, Please Select From The Dropdown All That Apply
Please Select
Agoraphobia
Anorexia nervosa
Antisocial personality disorder
Binge eating disorder
Bipolar disorder
Body dysmorphic disorder
Borderline personality disorder
Bulimia
Claustrophobia
Cyclothymia
Depression
Dissociative disorders
Generalised anxiety disorder (GAD)
Health anxiety
Hoarding disorder
Munchausen syndrome
Obsessive compulsive disorder (OCD)
Panic disorder
Phobias
Post-traumatic stress disorder (PTSD)
Psychosis
Psychotic depression
Schizophrenia
Seasonal affective disorder (SAD)
Selective mutism
Skin picking disorder
Social anxiety (social phobia)
Stress
Trichotillomania (hair pulling disorder)
13
Does The Young Person Have Any Medical Conditions? If Yes, Please Select From The Dropdown All That Apply
Please Select
Anaemia
Arthritis
Asthma
Back Pain
Cancer
Cardiovascular Disorder
Cerebrovascular Disease (including strokes)
Chronic Obstructive Pulmonary Disease (COPD)
Coronary Artery Disease
Coronary Heart Disease
Crohn's Disease
Diabetes Type 1
Diabetes Type 2
Drug Misuse
Eczema
Epilepsy
Heart Murmur
HIV
Irritable Bowel Syndrome (IBS)
Migraine Headaches
Multiple Sclerosis
Muscular Dystrophy
Osteoporosis
Overactive Bladder
Posterior Vitreous Detachment
Postural Hypotension
Pulmonary Hypertension
Renal Failure
Sickle Cell Disease
Underactive Thyroid
14
In your view what level of staff ratio is right for the young person being referred?* This field is required.
Please Select
Please Select
1 Staff Member to 1 Child (1:1)
1 Staff Member to 2 Children (1:2)
1 Staff Member to 3 Children (1:3)
Other
15
Does The Young Person Use A Wheelchair?* This field is required.
Please Select
Please Select
No
Yes - Occasionally
Yes - Always
16
Name Of Young Person's School* This field is required.
Please Select
Please Select
Altmore Infant School
Avenue Primary School
Bobby Moore Academy
Brampton Manor Academy
Brampton Primary School
Britannia Village Primary School
Calverton Primary School
Carpenter's Primary School
Central Park Primary School
Chobham Academt
Cleves Primary School
Colegrave Primary School
Curwen Primary School
Dersingham Primary School
Drew Primary School
Earlham Primary School
Eastlea Community School
Eko Pathways School
Ellen Wilkinson Primary School
Elmhurst Primary School
Essex Primary School
Gainsborough Primary School
Gallions Primary School
Godwin Primary School
Grange Primary School
Hallsville Primary School
Harris Science Academy
Hartley Primary School
John F Kennedy Special School (JFK)
Kaizen Primary School
Keir Hardie Primary School
Kensington Primary School
Kingsford Community School
Langdon Academy
Lathom Junior School
Lister Community School
Little Ilford School
London Academy of Excellence
Manor Primary School
Maryland Primary School
Monega Primary School
Nelson Primary School
New City Primary School
Newham College of Further Education
Newham Collegiate Sixth Form Centre
Newham Sixth Form College (New Vic)
North Beckton Primary School
Oasis Academy Silvertown
Odessa Infant School
Park Primary School
Plaistow Primary School
Plashet School
Portway Primary School
Ranelagh Primary School
Ravenscroft Primary School
Rokeby School
Roman Road Primary School
Rosetta Primary School
Royal Docks Academy
Royal Wharf Primary School
Salisbury Primary School
Sandringham Primary School
Sarah Bonnell School
School 21
School 360
Scott Wilkie Primary School
Selwyn Primary School
Shaftesbury Primary School
Sheringham Primary School
Sir John Heron Primary School
Southern Road Primary School
St Angela's Ursuline School
St Anthony's Catholic Primary School
St Bonaventure's RC School
St Edward's Catholic Primary School
St Francis' Catholic Primary School
St Helen's Catholic Primary School
St James' Church of England Primary School
St Joachim's Catholic Primary School
St Luke's Primary School
St Michael's Catholic Primary School
St Stephen's Primary School
St Winefride's RC Primary School
Star Primary School
Stratford School Academy
The Cumberland School
Tollgate Primary School
Upton Cross Primary School
Vicarage Primary School
West Ham Church Primary School
William Davies Primary School
Winsor Primary School
Woodgrange Infant School
Other
17
Is The Young Person?* This field is required.
Temporarily Excluded
Permanently Excluded
Not Applicable
18
Is The Young Person Known To:* This field is required.Please select all that apply
Children and Young People Services (0-25)
Child and Adolescent Mental Health Services (CAMHS)
Health Visitors
Youth Offending Team
Probation Service
Other Voluntary/Community Groups
None
Other
19
Please Provide The Details For The Contact Selected Above, Including Name, Role, Email and Phone Number* This field is required.
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Ok
Ok
20
Does The Young Person Have An EHCP?* This field is required.If yes, please send to paula@theaaazone.com upon completion of this form
YESNO
21
Reason For Referral* This field is required.Please provide as much detail as possible
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Ok
Ok
22
What Are You Hoping To Achieve For The Young Person Through This Referral?Please provide as much detail as possible
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Ok
Ok
23
Has The Young Person Been Involved In Any Criminal Activity Or Antisocial Behaviour?* This field is required.
YESNO
24
If Yes, Please Provide Details Including Any Outcomes
25
Please Outline Any Medication Currently Being Taken By The Young Person And Any Other Medical Needs Not Mentioned Previously * This field is required.
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Large
Normal
Small
Ok
Ok
26
Please Outline Any Personal Care Needs (if applicable)
27
Please Detail Any Behavioural Needs And/Or Difficulties* This field is required.
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Large
Normal
Small
Ok
Ok
28
Brief Outline Of Any Family History Relevant To The Referral Being Made* This field is required.
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Small
Ok
Ok
29
Any Other Relevant Information That May Be Useful* This field is required.
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Small
Ok
Ok
30
Have The Family Agreed To The Referral?* This field is required.
YESNO
31
Has The Young Person Agreed To The Referral?* This field is required.
YESNO
32
Please Select From The Options Below Which Project(s) You Would Like To Refer The Young Person To:* This field is required.Please note these projects run both weekend and during the week, some do not run during school holidays. All projects run at either of our hubs in Canning Town and Stratford or other selected location around Newham. If you would like more detail on any of these projects please check out our 'What's On' pages for all our hubs on our website - www.theaaazone.com
LEGO Clubs (Ages 5 to 11) (not suitable for one to one support)
Wellbeing Group (Ages 8 to 15) (not suitable for one to one support)
Garden Rangers (Ages 5 to 11) (not suitable for one to one support)
SEND Youth Club (Ages 10 to 25, 1:4 ratio)
SEND Positive Transitions (Ages 16 to 25, 1:4 ratio)
Multisports Club (Ages 9+, SEND Inclusive)
Cycling Club (Ages 5 to 11) (not suitable for one to one support)
General Youth Club (Ages 10 to 14) (not suitable for one to one support)
Afterschool Club (Ages 5 to 11) (not suitable for one to one support)
Saturday Play Spot (Ages 5 to 11) (not suitable for one to one support)
Woodland Warriors (Ages 5 to 11) (not suitable for one to one support)
33
Name of Referrer* This field is required.
First Name
Last Name
34
Referrer's Email Address* This field is required.
example@example.com
35
Referrer's Organisation* This field is required.
36
Referrer's Signature* This field is required.
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