Referral Form

Transforming Spaces - Referral Form
Our services are currently only available to families living in London.

This form will take 15 - 30 minutes. To complete it, you will need:
- Information on furniture the family requires
- Photos/videos of the bedrooms.
The form has 4 sections. The first two should be completed by you. The third section should be completed by you with answers from the parents or carers of the family. The final section should be completed by you with answers from the children in the family.

This means you will need to be with, or on the phone to, the whole family when completing this form. You must NOT complete the form based on what you think their answers would be, you MUST use their actual words.

By completing this form, you agree to The Childhood Trust using this data for their impact and research work.
Section A: this section is for the referrer to complete
A.1. Referral organisation details
Type organisation*
Organization Borough
Entity
Does the NHS provider belong to a trust?
Does the school belong to a trust?
{label}
Register Number
Organisation Name (Charity or Trust)
Organisation Name (LB)
School Name
NHS provider Name
Organisation Name
Referral Organisation
If your entity is not listed below, please provide the details
Account Owner
Campaign
A.2. Referee details
A.2.1 - First Name*
A.2.2 - Last Name*
A.2.3 - Phone Number*
Please enter a valid phone number. DO NOT include (+44)Format: 000-0000-0000.
A.2.4 - Email*
example@example.com
A.2.5 - Alternate Email
example@example.com
Be present for a site visit with the family at the home on the date specified by The Childhood Trust (or another date as arranged)Complete an impact evaluation form 1 week after the project is completedSupport the family to complete an impact evaluation form 1 week after the project is completedComplete an impact evaluation form 3 months after the project is completed (or handover to a colleague or other organisation working with the family so that they can do so)Support the family to complete an impact evaluation form 3 months after the project is completed (or handover to a colleague or other organisation working with the family so that they can do so)
A.3. Family details
A.3.1 - Family contact name*
First Name and Surname
A.3.2 -Main family email*
example@example.com
A.3.3 - Main family contact number*

Area CodePhone Number
A.3.4 -What is the child's current parental or guardian arrangement?
A.3.5 -What is the current employment status of the parent(s) or guardian(s)?
A.3.6 - Do any of the children being referred have additional learning or sensory needs, or are they neurodivergent?
A.4. Location
A.4.1 - Address*
House number and street
A.4.2 - Postal Code*
A.4.3 - Borough*
A.4.4 - City
A.5. Children
A.5.1 - Number of children in household*
A.5.2 - Child 1 Name*
Child 1 DOB*

DayMonthYear
Date
Child 1 Gender*
A.5.3 - Child 2 Name
Child 2 DOB

DayMonthYear
Date
Child 2 Gender
A.5.4 - Child 3 Name
Child 3 DOB

DayMonthYear
Date
Child 3 Gender
A.5.5 - Child 4 Name
Child 4 DOB

DayMonthYear
Date
Child 4 Gender
A.5.6 - Child 5 Name
Child 5 DOB

DayMonthYear
Date
Child 5 Gender
A.5.7 - Child 6 Name
Child 6 DOB

DayMonthYear
Date
Child 6 Gender
A.6. Property detail
A.6.1 - Number of bedrooms referred*
A.6.2 - Housing situation*
A.6.3 - If other, please outline below housing situation:
A.6.4 -Please tell us more about why you are referring this family and property to the programme and how it meets our criteria. Do not include any sensitive or safeguarding information in this answer.
YesNo
A.7 - Pictures

Please upload a variety of images to show the bedrooms including - existing/broken furniture, wall paint, all areas of the rooms.
A.7.1 - Photos:

Maximum 2 pictures
Cancelof
A.7.2 - Photos:

Maximum 2 pictures
Cancelof
A.7.3 - Photos:

Maximum 2 pictures
Cancelof
A.7.4 - Please could you add other pictures?

Maximum 2 pictures
Cancelof

A.8. Furniture and bedroom

Please rate your thoughts on the following areas currently:
A.8.1 - Furniture condition*
A.8.2 - Furniture quality*
A.8.3 - Essential*
A.8.4 - Bedroom decor*
A.8.5 - Study/homework space in bedroom*
A.8.6 - Space for playing/activities in bedroom*
A.8.7 - Room equipped for child's special/specific needs*
A.8.8 - Describe the current condition of the children's bedroom?*
Please feel free to refer to information written on the previous page if you feel you have already covered this question
A.8.9 - What is your observation of the children in relation to their bedroom?*
A.8.10 - What is your observation of the carer/parents in relation to their children's bedroom?*

Section B: this section is for the referrer to complete with answers from the parents/carers
The Childhood Trust is a charity in England and Wales with registration number 1154032. The Childhood Trust runs a programme called Transforming Spaces which refurbishes children’s bedrooms and community spaces with the help of volunteers.

Please read the below information carefully and get in touch with us (programmesupport@childhoodtrust.org.uk) if you have any questions.
- I agree that my family want to participate in the project.
- I agree to cooperate with charity staff throughout the project, and will tell them if I have any concerns.
- I understand that charity staff will be in contact with me and my referrer throughout the project, and I agree to be responsive.
- I give my consent for volunteers to enter and work in my property during the project.
- I understand that participation in the project may require my cooperation in the following circumstances:
- Receiving furniture deliveries at my home before the project date.
- Clearing personal items from the bedrooms prior to the project date.
- Professional services entering my home to do specific tasks such as decoration and furniture building.
- Photographs being taken of the bedroom after the transformation has been completed (nothing identifiable will be pictured).
I agree to inform my referrer and The Childhood Trust immediately if there are any changes to the household which may affect health and safety or safeguarding. I understand that not doing this may result in the cancellation of the project.

I agree to complete a post project evaluation form straight after the project and 3 months after the project.

The Childhood Trust, will at times, invite members of its external partner (Katherine Pooley Ltd.) to attend site visits along with the referral partner. I understand and agree that any pictures taken by this partner may be used for their marketing purposes unless otherwise discussed at the site visit.

Data privacy statement: https://www.childhoodtrust.org.uk/privacy-policy/
I have carefully read and understood the information above:*

First NameLast Name
YesNo
YesNo
B.3 - Please answer the following questions in relation to all your children who are having room redecorations.
B.3.1 - My child's bedroom is generally: *
1 - In very poor condition 5 - In excellent condition
B.3.2 - My child's bedroom furniture condition (if its broken/ wonky) is in:*
1 - In very poor condition 5 - In excellent condition
B.3.3 - My child's bedroom has:*
1 - No essential items 5 - All essential items and extras
B.3.4 - My child's bedroom caters to their special/ specific needs (leave blank if not applicable):
1 - Disagree strongly 5 - Strongly agree
B.3.5 - My child's study space situation is:*
1 - They have nowhere in the home that is appropriate 5 - They have their own desk and chair in their room
B.3.6 - My child is able to concentrate on their homework/ studies in their bedroom:*
1 - Never 5 - All the time
B.3.7 - My child's bedroom furniture quality (how well it's made/ materials used) is:*
1 - Very poor quality 5 - Excellent quality
B.3.8 - I feel stressed when thinking about my child's bedroom*
1 - All the time 5 - Never
B.3.9 - I feel down or negative when thinking about my child's bedroom*
1 - All the time 5 - Never
B.3.10 - I feel worried about my child in relation to their bedroom*
1 - All the time 5 - Never
B.3.11 - Can you tell us your current thoughts and feeling about your child's bedroom? (this must be answered by the parent/carer - this should not be the referrers perspective) *

Section C: this section is for the referrer to complete with answers from the children/young people.

All children (over 5) who are being referred, should answer these questions.
Child 1 : Name*

First NameLast Name
C.1.1 - What is your age?*
C.1.2 - I feel happy in my room
1 - Never 5 - Always
C.1.3 - I like to call my friends over to visit
1 - Never 5 - Always
C.1.4 - I feel comfortable in my room
1 - Never 5 - Always
C.1.5- I can concentrate on learning in my room
1 - Never 5 - Always
C.1.6 - My room makes me feel relaxed
1 - Never 5 - Always
C.1.7 - I sleep well in my room
1 - Never 5 - Always
C.1.8 - My bedroom has everything I need in it
1 - Nothing 5 - Everything and more
C.1.9 - I like how my rooms looks
1 - Strongly disagree 5 - Strongly agree
C.1.10 - I feel proud of my room
1 - Strongly disagree 5 - Strongly agree
C.1.11 - My bedroom has enough space for me and my things
1 - Not enough space for anything I need 5 - Fits everything I need and still has space left
C.1.12 - Can you tell us what you like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.1.13 - Can you tell us what you don't like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.1.14 - Can your describe your room in 3 words?
Child 2 : Name

First NameLast Name
C.2.1 - What is your age?
C.2.2 - I feel happy in my room
1 - Never 5 - Always
C.2.3 - I like to call my friends over to visit
1 - Never 5 - Always
C.2.4 - I feel comfortable in my room
1 - Never 5 - Always
C.2.5 - I can concentrate on learning in my room
1 - Never 5 - Always
C.2.6 - My room makes me feel relaxed
1 - Never 5 - Always
C.2.7 - I sleep well in my room
1 - Never 5 - Always
C.2.8 - My bedroom has everything I need in it
1 - Nothing 5 - Everything and more
C.2.9 - I like how my rooms looks
1 - Strongly disagree 5 - Strongly agree
C.2.10 - I feel proud of my room
1 - Strongly disagree 5 - Strongly agree
C.2.11 - My bedroom has enough space for me and my things
1 - Not enough space for anything I need 5 - Fits everything I need and still has space left
C.2.12 - Can you tell us what you like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.2.13 - Can you tell us what you don't like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.2.14 - Can your describe your room in 3 words?
Child 3 : Name

First NameLast Name
C.3.1 - What is your age?
C.3.2 - I feel happy in my room
1 - Never 5 - Always
C.3.3 - I like to call my friends over to visit
1 - Never 5 - Always
C.3.4 - I feel comfortable in my room
1 - Never 5 - Always
C.3.5 - I can concentrate on learning in my room
1 - Never 5 - Always
C.3.6- My room makes me feel relaxed
1 - Never 5 - Always
C.3.7- I sleep well in my room
1 - Never 5 - Always
C.3.8 - My bedroom has everything I need in it
1 - Nothing 5 - Everything and more
C.3.9 - I like how my rooms looks
1 - Strongly disagree 5 - Strongly agree
C.3.10 - I feel proud of my room
1 - Strongly disagree 5 - Strongly agree
C.3.11 - My bedroom has enough space for me and my things
1 - Not enough space for anything I need 5 - Fits everything I need and still has space left
C.3.12 - Can you tell us what you like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.3.13 - Can you tell us what you don't like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.3.14 - Can your describe your room in 3 words?
Child 4 : Name

First NameLast Name
C.4.1 - What is your age?
C.4.2 - I feel happy in my room
1 - Never 5 - Always
C.4.3 - I like to call my friends over to visit
1 - Never 5 - Always
C.4.4 - I feel comfortable in my room
1 - Never 5 - Always
C.4.5 - I can concentrate on learning in my room
1 - Never 5 - Always
C.4.6 - My room makes me feel relaxed
1 - Never 5 - Always
C.4.7 - I sleep well in my room
1 - Never 5 - Always
C.4.8 - My bedroom has everything I need in it
1 - Nothing 5 - Everything and more
C.4.9 - I like how my rooms looks
1 - Strongly disagree 5 - Everything and more
C.4.10- I feel proud of my room
1 - Strongly disagree 5 - Strongly agree
C.4.11 - My bedroom has enough space for me and my things
1 - Not enough space for anything I need 5 - Fits everything I need and still has space left
C.4.12 - Can you tell us what you like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.4.13- Can you tell us what you don't like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.4.14 - Can your describe your room in 3 words?
Child 5 : Name

First NameLast Name
C.5.1 - What is your age?
C.5.2 - I feel happy in my room
1 - Never 5 - Always
C.5.3 - I like to call my friends over to visit
1 - Never 5 - Always
C.5.4 - I feel comfortable in my room
1 - Never 5 - Always
C.5.5 - I can concentrate on learning in my room
1 - Never 5 - Always
C.5.6 - My room makes me feel relaxed
1 - Never 5 - Always
C.5.7 - I sleep well in my room
1 - Never 5 - Always
C.5.8 - My bedroom has everything I need in it
1 - Nothing 5 - Everything and more
C.5.9 - I like how my rooms looks
1 - Strongly disagree 5 - Everything and more
C.5.10- I feel proud of my room
1 - Strongly disagree 5 - Strongly agree
C.5.11 - My bedroom has enough space for me and my things
1 - Not enough space for anything I need 5 - Fits everything I need and still has space left
C.5.12 - Can you tell us what you like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.5.13 - Can you tell us what you don't like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.5.14 - Can your describe your room in 3 words?
Child 6 : Name

First NameLast Name
C.6.1 - What is your age?
C.6.2 - I feel happy in my room
1 - Never 5 - Always
C.6.3 - I like to call my friends over to visit
1 - Never 5 - Always
C.6.4 - I feel comfortable in my room
1 - Never 5 - Always
C.6.5 - I can concentrate on learning in my room
1 - Never 5 - Always
C.6.6 - My room makes me feel relaxed
1 - Never 5 - Always
C.6.7 - I sleep well in my room
1 - Never 5 - Always
C.6.8 - My bedroom has everything I need in it
1 - Nothing 5 - Everything and more
C.6.9 - I like how my rooms looks
1 - Strongly disagree 5 - Everything and more
C.6.10 - I feel proud of my room
1 - Strongly disagree 5 - Strongly agree
C.6.11 - My bedroom has enough space for me and my things
1 - Not enough space for anything I need 5 - Fits everything I need and still has space left
C.6.12 - Can you tell us what you like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.6.13 - Can you tell us what you don't like about your room?
(this must be answered by the child - this should not be the referrers perspective)
C.6.14 - Can your describe your room in 3 words?
Baseline Survey Name
Midpoint Survey Name
Final Survey Name
Should be Empty:

Transforming Spaces - Referral Form

Section A: this section is for the referrer to complete

A.1. Referral organisation details

A.2. Referee details

A.3. Family details

A.4. Location

A.5. Children

A.6. Property detail

A.7 - Pictures

A.8. Furniture and bedroom

Section B: this section is for the referrer to complete with answers from the parents/carers

Section C: this section is for the referrer to complete with answers from the children/young people.