YCSW Alternative Education

YCSW Alternative Education - Referral Form
Referring Agency/Name
E-mail (referrer)
example@example.com
Phone Number (referrer)
Please enter a valid phone number.
Referral Date

DayMonthYear
Date
Which programme are you referring to?
Which academic year would they like to start
Young Person’s Name (and preferred name)
Date of birth

MonthDayYear
Date
Gender identity
Preferred pronouns
Ethnicity (eg. White British, Black Caribbean)
Address (YP)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (YP)
Please enter a valid phone number.
Email (YP)
example@example.com
Does the YP have an EHCP? (requirement for L4W and P4L)

YesNo
SEND practitioners name (if known):
Parent/carer contact details
Current education setting
Year Group
Attendance (%)
Please note – There are limited spaces on our programmes; a referral does not guarantee a place. YCSW will aim respond to the referrer to discuss the process within 3 days.
Current/previous provision
Preferred site (L4W only):

RadstockSouthside Youth CentreN/A
Can the young person travel independently or do they have support with transport?
What level is the young person likely to be working towards (if known) or what is the highest level qualification held?
Please tick all additional factors which apply to the young person’s current situation

Disrupted educationEmotional/mental health challengesRisk of CSESignificant health problemsSignificant home or family issuesLow emotional resilienceInvolvement in risky behaviourHistory of poor school attendance, below 85%Social isolationChallenging behaviourHistory of offending/custodyAddictive behaviour(s)
Please tick all other agencies which are involved with the young person

CAMHSSocial Care (please specify team)Youth Offending Service (YOS)Project 28Mentoring PlusSouthside / BAPP
Please list any other professionals involved or any additional information about services working with the young person
Supporting information for the referral. Why is the young person being referred to L4W/P4L/ESS?
Young Person’s comments, what would they like to achieve?
Is the young person aware of and have they consented to this referral:
Young person’s signature (optional)

Clear
Alternative signature (YP) - print name
Referrer signature

Clear
Alternative signature (Referrer) - print name
YCSW will hold information you have provided on this form securely in an electronic database. By completing this form you agree to share your information with YCSW staff.
Please verify that you are human*
Should be Empty:

YCSW Alternative Education - Referral Form