Chance UK Referral Form

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Explore and Empower
Islington - Closed for referrals
Lambeth - Closed for referrals

My Future
Camden - Closed for referrals
Southwark - Closed for referrals

Safer Space+
Haringey, Islington, Westminster, Croydon, Southwark and Lambeth - Closed for referrals
STEP
Islington (different referral form, please see our website) - Closed for referrals

In order to access our programme content, children will need to: speak and comprehend English to an age appropriate level, and not have a diagnosis of Autistic Spectrum Condition. Please tick the box to confirm that the child has age-appropriate language and has not got an ASC diagnosis, or an assessment in progress.

It is vital that referrers have discussed and obtained consent and support from the parent/carer and child to be referred to Chance UK. Do not begin completing this referral without their consent. By submitting any information to Chance UK, referrers will be indicating that the parent/carer and child have given their consent to have their information shared with Chance UK. Please tick this box to confirm.

Please confirm that this child is currently in primary school years 1-6.

CHILD

First name(s) of child	Surname of child
Other names used for the child
Date of Birth	Gender
Current School Year (Discard)Name of the teacher completing this: Please select a borough from this drop-down list where the child referred is either a resident or pupil, or both: To your knowledge, has the child ever witnessed or experienced domestic violence or abuse? Do you know of any reason that staff or volunteers could be at risk of harm in or around the family home?

SCHOOL

Referrer's First name	Referrer's Surname
Referrer's role	Name of School
School Address Street
School Address City
Post Code
Referrer's Phone	Referrer's Email

SCHOOL BEHAVIOURAL ASSESSMENT

Goodman Strengths and Difficulties Questionnaire (SDQ)

Please rate the child’s behaviour over the last six months, or over the last school year,

by selecting one answer in each row below.

Name of the teacher completing this:

Role at School:

	Not True	Somewhat True	Certainly True
Considerate of other people's feelings
Restless, overactive, cannot stay still for long
Often complains of headaches, stomach aches or sickness
Shares readily with other children (treats, toys, pencils etc.)
Often has temper tantrums or hot tempers
Rather solitary, tends to play alone
Generally obedient, usually does what adults request
Many worries, often seems worried
Helpful if someone is hurt, upset or feeling ill
Constantly fidgeting or squirming
Has at least one good friend
Often fights with other children or bullies them
Often unhappy, down-hearted or tearful
Generally liked by other children
Easily distracted, concentration wanders
Nervous or clingy in new situations, easily loses confidence
Kind to younger children
Often lies and cheats
Picked on or bullied by other children
Often volunteers to help others(parents, teachers, other children
Thinks things out before acting
Steals from home, school or elsewhere
Gets on better with adults than with other children
Many fears, easily scared
Sees tasks through to the end, good attention span

MAIN CARER BEHAVIOURAL ASSESSMENT

Goodman Strengths and Difficulties Questionnaire (SDQ)

Please rate the child’s behaviour over the last six months, or over the last school year,

by selecting one answer in each row below.

Name of the parent/carer completing this:

Relationship to Child:

	Not True	Somewhat True	Certainly True
Considerate of other people's feelings
Restless, overactive, cannot stay still for long
Often complains of headaches, stomach aches or sickness
Shares readily with other children (treats, toys, pencils etc.)
Often has temper tantrums or hot tempers
Rather solitary, tends to play alone
Generally obedient, usually does what adults request
Many worries, often seems worried
Helpful if someone is hurt, upset or feeling ill
Constantly fidgeting or squirming
Has at least one good friend
Often fights with other children or bullies them
Often unhappy, down-hearted or tearful
Generally liked by other children
Easily distracted, concentration wanders
Nervous or clingy in new situations, easily loses confidence
Kind to younger children
Often lies and cheats
Picked on or bullied by other children
Often volunteers to help others(parents, teachers, other children
Thinks things out before acting
Steals from home, school or elsewhere
Gets on better with adults than with other children
Many fears, easily scared
Sees tasks through to the end, good attention span

PRIVACY NOTICE: We would like the parent/carer's permission to hold this referral form securely for 2 years before deleting it. We ask this because we may internally review multiple anonymous referral forms to help us see what services families may need in the future. If Chance UK develops a new service that we think may suit your child or you, we may also like to contact you about this in the next 2 years. We will never rent, swap or sell you or your family's personal information to any other organisations. Are you willing for Chance UK to hold the information you have shared here securely for up to 2 years?

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