(New) Targeted Support Referral Form

Youth Connect South West - Targeted Support Referral Form
Before making a referral, the service must be discussed with the young person and their consent obtained. Please confirm that the young person has agreed to this referral.*

Yes
Referring Agency
Referrers Name*
Agency*
Referrers Phone Number *
Referrers Email*
example@example.com
Referral Date*

DayMonthYear
Date
Young Person’s Details
Name*

First NameLast Name
Preferred name (if different to the one above)
Date of Birth*

DayMonthYear
Date
Gender identity*
Preferred Pronouns
Ethnicity (e.g., White British, Black Caribbean)*
Address (YP)*

Street Address

Street Address Line 2

CityCounty

Post Code
Contact Details for YP*
SEN, Medical or Dietary Needs*
Parent/Carer Contact Details*
Current Education Setting
Year group *
Attendance %*
Name of current education setting*
Reasons for Referral

Please refer to the guidance notes on the next page and provide additional details about any issues or factors you have indicated as relevant.
Please select the primary support the young person is being referred for

YP aged 16-18 (or up to 25 with a current EHCP) - Not in Education Employment or Training (NEET)Young Person at High Risk of NEET – Year 11, 12 or 13YP experiencing Significant Issues 13-18yrs and in need of additional targeted support
Risk of becoming NEET (Not in Education, Employment or Training) is based on nationally recognised risk factors. Please tick all factors that apply to the young person.

Low academic attainmentPoor school attendance – below 90%Behavioural issues – including exclusions and disciplinary incidents.Special Educational Needs and Disabilities (SEND) – especially without an Education, Health and Care Plan (EHCP).Social, emotional, and mental health needs (SEMH) – impacting engagement and progress.Looked After Children (LAC) or care leavers – increased vulnerability to becoming NEET.Young carersPupil Premium eligibilityEnglish as an Additional Language (EAL)Involvement with youth justice systemFamily or housing instability
Young people will be eligible for a service, where one or more of the following issues are present: Select all factors that apply to the young person

Experiencing social, emotional and mental health difficulties, including low confidence and self-esteemNot engaging with schoolDisplaying challenging or withdrawal behaviour and affected by social and cultural isolationAt risk of exploitationIn or leaving care (up to age 21)Other
Are any other professionals or services currently involved with the young person or their family? (e.g. CAMHS, Social Care, YOS, Project 28, Mentoring Plus, Southside). Please provide Name, Agency & Contact Details
Has another assessment been completed in the last 12months?*

YesNo
If you do have an assessment please upload here

Cancelof
Referrers Comments - Why is Targeted Support required? What support has already been provided or attempted? *
What outcomes are you hoping this support will help the young person achieve? (Please tick all that apply)

Improved emotional resilienceBetter mental healthGreater independence, confidence, and self-esteemMaking healthier choicesEngaged in education, employment or training, with goals for the futureFeeling safe and protectedInvolved in their local community
Young person’s comments – What support would you like from us?*
What is the best way for us to get in contact?

Text or call YP mobileEmail YPParent/carerThrough schoolContact referrer
Please verify that you are human*
Guidance Notes

The service will provide targeted support and interventions to young people who are at risk of experiencing poor outcomes, associated with being at risk of NEET (not in education, employment or training) or are actually NEET and not eligible for other services.

The service will improve outcomes for young people and reduce inequalities by;
- Helping young people overcome barriers to fully engage in education, employment or training,
- Undertaking statutory duties in relation to tracking young people’s participation as outlined in the statutory guidance for local authorities (DfE, 2024) as specified in the description of service.
- Providing support and interventions that will engage vulnerable young people to help them develop resilience, improve emotional and mental wellbeing and make a positive difference to their lives and to their communities.
Targeted Youth Support is available for young people resident in Bath and North East Somerset aged 13-19 (up to 25 for those with additional needs, special educational needs and/or disabilities) at risk of being not in education, employment or training (NEET) or those who are actually NEET and not eligible for other services.

Consent

All referrals must be discussed with and agreed by the young person. If the young person is under 14, parents or carers must also give their consent.

Our support is voluntary, so it’s important the young person understands the referral and agrees to take part.

If you’d like to discuss a referral, please email targeted.referrals@ycsw.org.uk or call 01225 396980 and leave your contact details. A member of our team will get back to you.

Data Protection

Youth Connect South West will use the information you provide to offer you the right support. Your personal data will be handled in line with the Data Protection Act 2018 (GDPR) and will only be shared with your consent - unless required by law for safeguarding or other legal reasons.

For more information, you can contact our team on 01225 235659.
You can also view our privacy notice on the Youth Connect South West website https://www.youthconnectsouthwest.org.uk/policies.
Should be Empty:

Youth Connect South West - Targeted Support Referral Form

Referring Agency

Young Person’s Details

Current Education Setting

Reasons for Referral

Guidance Notes