Primary RESET Referral Form

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To ensure we are supporting the students who would benefit most from the Illuminate AP RESET programme, we have outlined specific referral criteria. Referrals should align with the following criteria:* This field is required.
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Welcome to Illuminate AP's referral form. Please provide us with your name* This field is required.
First Name
Last Name
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Please provide your Contact Email* This field is required.
example@example.com
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Please provide a contact number* This field is required.
5
Please provide the name of the referring school* This field is required.
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Please provide the details of the Designated Safeguarding Lead* This field is required.
Name
Please enter your phone
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Young Person's Name* This field is required.
First Name
Last Name
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Young Person's Year Group and D.O.B* This field is required.
Year Group
D.O.B
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Ethnicity* This field is required.
10
English as an additional language * This field is required.
YESNO
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Is this young person entitled to free school meals?* This field is required.
YESNO
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Have the Parents/Carers been informed of this referral* This field is required.
YESNO
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Parent/Carer Name* This field is required.
First Name
Last Name
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Home Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Post 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
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Parent/Carer Contact Phone Number* This field is required.
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Parent/Carer Email Address* This field is required.
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Young Person's current attendance %* This field is required.
18
Is this young person open to Children and Social Care?* This field is required.
Please Select
Please Select
Yes currently open to CSC
No but history of CSC involvement
No and no history of CSC involvement
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Is the child currently on any of the following plans or receiving support from the following agencies?* This field is required.
Child Protection
Child In Need
Early Help
LAC
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Please provide an overview of current or historical involvement with CSC. Please include current Social Worker contact names, contact number and email address.
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Ok
Ok
21
Please detail any home concerns (Inc Personal Hygiene, Relationships, Living Conditions)* This field is required.
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Ok
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Is this young person gifted or talented?* This field is required.
YESNO
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Does this young person have special Educational needs or disabilities (SEND)?"* This field is required.
Please Select
Please Select
Yes
No
Please provide details
24
Does this young person have SEMH needs?* This field is required.
Please Select
Please Select
Yes
No
Please provide details
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Does this Young Person have or in the process of being assessed for an EHCP?* This field is required.
Yes EHCP issued
No currently being assessed for an EHCP
No
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Current school levels * This field is required.
English
Maths
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Please provide the number of previous exclusions (Dates / Reasons)* This field is required.
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Please outline the main areas of concern and reason for referral* This field is required.
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Please complete the following risk assessment * This field is required.
Never
Rare
Occasional
Frequent
Persistent
Self-Harm
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Row 0, Column 3
Row 0, Column 4
Bullying
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Abusive or violent language
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Sexually Abusive
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Violent Behaviour
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Impulsive/Dangerous Behaviour
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Substance/ Alcohol Misuse
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Prejudice
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Absconding
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Row 8, Column 3
Row 8, Column 4
Damage to Property
Row 9, Column 0
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Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Offending Behaviour
Row 10, Column 0
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Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Carrying/ Use of Weapons
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Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Self-Harm
Bullying
Abusive or violent language
Sexually Abusive
Violent Behaviour
Impulsive/Dangerous Behaviour
Substance/ Alcohol Misuse
Prejudice
Absconding
Damage to Property
Offending Behaviour
Carrying/ Use of Weapons
Never
Row 0, Column 0
Rare
Row 0, Column 1
Occasional
Row 0, Column 2
Frequent
Row 0, Column 3
Persistent
Row 0, Column 4
Never
Row 1, Column 0
Rare
Row 1, Column 1
Occasional
Row 1, Column 2
Frequent
Row 1, Column 3
Persistent
Row 1, Column 4
Never
Row 2, Column 0
Rare
Row 2, Column 1
Occasional
Row 2, Column 2
Frequent
Row 2, Column 3
Persistent
Row 2, Column 4
Never
Row 3, Column 0
Rare
Row 3, Column 1
Occasional
Row 3, Column 2
Frequent
Row 3, Column 3
Persistent
Row 3, Column 4
Never
Row 4, Column 0
Rare
Row 4, Column 1
Occasional
Row 4, Column 2
Frequent
Row 4, Column 3
Persistent
Row 4, Column 4
Never
Row 5, Column 0
Rare
Row 5, Column 1
Occasional
Row 5, Column 2
Frequent
Row 5, Column 3
Persistent
Row 5, Column 4
Never
Row 6, Column 0
Rare
Row 6, Column 1
Occasional
Row 6, Column 2
Frequent
Row 6, Column 3
Persistent
Row 6, Column 4
Never
Row 7, Column 0
Rare
Row 7, Column 1
Occasional
Row 7, Column 2
Frequent
Row 7, Column 3
Persistent
Row 7, Column 4
Never
Row 8, Column 0
Rare
Row 8, Column 1
Occasional
Row 8, Column 2
Frequent
Row 8, Column 3
Persistent
Row 8, Column 4
Never
Row 9, Column 0
Rare
Row 9, Column 1
Occasional
Row 9, Column 2
Frequent
Row 9, Column 3
Persistent
Row 9, Column 4
Never
Row 10, Column 0
Rare
Row 10, Column 1
Occasional
Row 10, Column 2
Frequent
Row 10, Column 3
Persistent
Row 10, Column 4
Never
Row 11, Column 0
Rare
Row 11, Column 1
Occasional
Row 11, Column 2
Frequent
Row 11, Column 3
Persistent
Row 11, Column 4
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Please provide details of any other risks this young person may present with* This field is required.
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Please provide details of known behaviour triggers* This field is required.
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Please provide details of successful management strategies or coping mechanisms* This field is required.
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Current and Historical Interventions
Yes - Current
Yes - Historical
No
PSP - Personal Support Plan
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Row 0, Column 1
Row 0, Column 2
Group Work
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Therapy in school
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Referral to CAMHS
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Row 3, Column 1
Row 3, Column 2
Learning Mentor
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Referral to Early Help
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Referral to MASH
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Row 6, Column 1
Row 6, Column 2
Youth Services
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Counselling
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
YOT Involvement
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Educational Psychologist
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
PSP - Personal Support Plan
Group Work
Therapy in school
Referral to CAMHS
Learning Mentor
Referral to Early Help
Referral to MASH
Youth Services
Counselling
YOT Involvement
Educational Psychologist
Yes - Current
Row 0, Column 0
Yes - Historical
Row 0, Column 1
No
Row 0, Column 2
Yes - Current
Row 1, Column 0
Yes - Historical
Row 1, Column 1
No
Row 1, Column 2
Yes - Current
Row 2, Column 0
Yes - Historical
Row 2, Column 1
No
Row 2, Column 2
Yes - Current
Row 3, Column 0
Yes - Historical
Row 3, Column 1
No
Row 3, Column 2
Yes - Current
Row 4, Column 0
Yes - Historical
Row 4, Column 1
No
Row 4, Column 2
Yes - Current
Row 5, Column 0
Yes - Historical
Row 5, Column 1
No
Row 5, Column 2
Yes - Current
Row 6, Column 0
Yes - Historical
Row 6, Column 1
No
Row 6, Column 2
Yes - Current
Row 7, Column 0
Yes - Historical
Row 7, Column 1
No
Row 7, Column 2
Yes - Current
Row 8, Column 0
Yes - Historical
Row 8, Column 1
No
Row 8, Column 2
Yes - Current
Row 9, Column 0
Yes - Historical
Row 9, Column 1
No
Row 9, Column 2
Yes - Current
Row 10, Column 0
Yes - Historical
Row 10, Column 1
No
Row 10, Column 2
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If you answered Yes in the previous question, please provide further details including worker names, contact details and dates for each.
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Please provide details of any medical conditions, incl. Allergies* This field is required.
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Please provide details of any prescribed medication* This field is required.
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Please provide details of any dietary requirements* This field is required.
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Please provide details of any disabilities* This field is required.
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Please provide any other information which you feel may be relevant to supporting and meeting the needs of this young person* This field is required.
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Please provide an overview of why this young person meets Illuminate AP's referral criteria* This field is required.
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