Valour Youth

VALOUR YOUTH

CWD Support Application form
MIGHTY MEN OF VALOUR
Mentoring |Training | Advocacy | Employment
PO Box 1417, Croydon, Surrey, CR9 0XJ

T: 0800 073 1325; M: 07958 770 779; F: 020 8240 7485; W: http://www.mightymenofvalour.org
Office hours - Monday to Friday: 0800 073 1325 10.30am to 3.30pm

Out of office hours: 07958 770 779.

Mighty Men of Valour a Company Registered in England No.05515628
CHARITY REGISTRATION NO: 1128154
Young Persons/ Parents Contact Details

Young Person/ Parent/ Carer/ Guardian
Reason for this referral?*
Date of referral:

DayMonthYear
Child / Mentees Full Name*

PrefixFirst NameLast Name
Parent/Guardian Main Contact Details

Young Person/ Parent/ Carer/ Guardian
Parent / Guardian's Full Name - main contact *

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Postal CodeCountry
Mobile Number*

Area CodePhone Number
Phone Number*

Area CodePhone Number
E-mail*
Other Family Languages:
Parent/Guardian Second Contact Details

Young Person/ Parent/ Carer/ Guardian
Parent / Guardian's Full Name - (Second contact)

PrefixFirst NameLast Name
Parent's second contact address (if different from above)

Street Address

Street Address Line 2

CityCounty

Postal Code
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Young Persons details/support needs:
Date of Birth:*
Age *
Gender*

MaleFemaleN/A
Class/Form/Yr:
Child's family background /information*
Please add any information which is relevant to this young person e.g. siblings, concerns, etc.
How many hours support has been allocated to during School week? (Term-Time)*
Term-time (Eveings and Weekends)
How many hours support has been allocated to during School Holidays? (Non-Term Time) *
Holidays - (Monday to Sunday)
Special requirements during sessions (please list)*
Food, drink, medication, changing pads etc..
School Attended and Contact?
Health awareness*

Do you have a disability ?Do you have a learning difficulty?Do you suffer from Epilepsy?Do you take medication?AllergiesAutismAspergersADHDOCDMental health issuesOther
What is your ethnic group ?*

White BritishWhite IrishOther White backgroundBlack Caribbean and WhiteAsian and WhiteBlack African and WhiteOther Mixed backgroundIndianBangladeshiPakistaniOther Asian backgroundCaribbeanAfricanOther Black backgroundChineseOther
Pupil family background information (Please tick all that apply)*

Dual ParentsLone ParentLive with Carers/GuardiansIssues of DVChild Protection (CP)Child In Need (CIN)Other
Level of self- care skills (please tick all that apply)*

Needs help with Personal CareDoes NOT need help with Personal CareNeeds reminders for the toiletToilet training programNeeds pads or nappies changedDoes NOT need pads or nappies changedNeeds help feedingNeeds help dressing
Explain the severity of the diagnosis/ disability and how it is managed *
How can we best support this young person?
Displays anxiety by... (Please tick all that apply)*

Self-harmingShouting/swearingPhysical attackWithdrawalShakingAbscondingSpittingBitingOther
What are the triggers to cause anxiety and how can this anxiety be reduced?*
How can we best support this young person - Is anxiety casued by Noise, Ballons, Colours, Dogs, Other Children etc?
Preferred methods of communication (please tick all that apply)*

Verbal speech onlyVerbal assisted /signalongVerbal assisted / PECS and symbolsVerbal assisted/pointing and leadingOther
Reaction in group settings/ Do they like to be alone/ any sensory support they like?
How can we best support this young person - Feathers, Ballons, Sticks, Reduce Noise, Soothening Colours, Soft Toy etc?
How much Screen Time /Computer Time your child have at home/ during the day and are these sessions supervised*
How much Screen Time, including TV, Computers, Video Games, Tables, Mobile Phones etc.
Can we have a copy of the young person's Educational, Health and Care (ECH) plan?*

YesNoOther
Type of Support required and Outcomes:

Agreed Outcomes
Male or Female Mentor/Support Worker?:*

Male Support WorkerMale Support WorkerBoth Male and Female Support WorkerNo preferenceOther
Does the young person require:*

1:1 Support2:1 SupportPersonal CareOther
Activities most enjoyed (please list)*
Walking, Shopping, Parks, Playgrounds, Football, Swimming etc.
Are there any other professionals the we need to liaise with regarding this referral:

School/ Social Services/ /Head Teacher/Lead Professional etc.
Any other professionals involved*

SchoolSocial ServicesCAMHSSpeech and Language TherapistsOther
Who has made this referral:

Parent School/ Social Services/ /Head Teacher/Lead Professional
Name of person making the referral:*
Name of Person who has made the referral
Dept./Team*
E-mail*
example@example.com
Who has made this referral?*

SchoolSocial ServicesParent/FamilyOther
Child's Social Care Status*
Child Protection Plan Y/N*

YesNo
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Address (if different for Above)*

Street Address

Street Address Line 2

CityCounty

Postal Code
Can we have your managers/supervisors contact details please?

Parent School/ Social Services/ /Head Teacher/Lead Professional
Name of manager/supervisor of person making the referral:*
Name of Person's Manager/Supervisor who has made the referral
Dept./Team*
E-mail*
example@example.com
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
I/We consent to Mighty Men of Valour (Valour Youth) holding and using our Personal Data for the purpose of mentor/supporting this young person. Mighty Men of Valour (Valour Youth) will not pass your details to any third parties without your consent.
Permissions?

Parent Permissions
Do you give Valour Youth (MMOV) permission to Provide Support this child:*

YesNo
Do you give Valour Youth (MMOV) permission to take photographs/ video for Social Story, Personal Achievement etc.

YesNo
Do you give Valour Youth (MMOV) permission to give specified medication to your child:*

YesNo
Please state what type of Medication do you give our support worker to administer?
Medication Type
Where did you hear about our service?*

SchoolSocial ServicesParent/FamilyFriendColleagueWebsiteManagerOther
Signature of person making the Referral*
Signature of Parent/ Carer/ Guardian
Date of Signature*

MonthDayYear
Date
How will this support funded?
Who will be funding this support?*

SchoolSocial ServicesParent/FamilyOther
How many sessions required?*

Short termLong termOngoingOther
Please check and print referral form before submitting it.
For office use only
Payment Details/ Purchase Orders
Cost of Support per session
Start Referral received

MonthDayYear
Date
Payment Structure
Date Mentoring/ Support Started

MonthDayYear
Date

Young Persons/ Parents Contact Details

Parent/Guardian Main Contact Details

Parent/Guardian Second Contact Details

Young Persons details/support needs:

Type of Support required and Outcomes:

Are there any other professionals the we need to liaise with regarding this referral:

Who has made this referral:

Can we have your managers/supervisors contact details please?

Permissions?

How will this support funded?

For office use only