Referral form: LIFT, Safer Space, STEP, Westminster and Community Groups programmes

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Programmes

Click here for information on our different programmes and their acceptance criteria.

To which programme are you referring this child?

Permissions and policies

It is vital that referrers have discussed and obtained consent and support from the parent/carer and child to be referred to Chance UK. 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 ensure this is read to the parent/carer before submitting:

The programme for parents and carers runs alongside the mentoring and uses a mixture of 1:1 and group work. Our parent team will be in contact to explain more and for you to ask questions, and tell us what you need. You are more than welcome to contact one of the Chance UK Parenting Team before then or look at website to find out more.

By consenting to this referral to Chance UK, the parent/carer is committing to take part in the support offered to parents and carers, that runs alongside mentoring. Please tick this box to confirm.

Families should be aware that Chance UK mentors and staff come from all walks of life and we are proud to accept them according to their merits, regardless of their ethnic origin, gender, disability, religious belief, sexual orientation or age.

We strive to achieve equality of opportunity, and we value difference and inclusiveness.

Our Equality of Opportunity and Valuing Diversity policy is available here. Does the family consent to adhering to this policy and treating all staff and volunteers fairly?

YesNo

CHILD

First name(s) of child	Surname of child
Other names used for the child
Date of birth	Borough
Gender	School Year
Ethnicity	Faith
If other/mixed ethnicity please specify Please confirm that the child can speak and comprehend English to an age-appropriate level, with a necessary level of communication and self-reflection skills to engage fully with our mentoring programme: YesNo	If other faith, please specify

MAIN CARER

Main carer's first name	Main carer's last name
Main carer's relationship to the child
Phone Number	Alternative contact method e.g. email
Home Address Street
Home Address City
Post Code

Do you wish to add details of additional family members?

OTHER FAMILY MEMBERS

First name	Last name
Relationship to the child
Phone Number	Alternative contact method e.g. email
Home Address Street
Home Address City
Post Code

FAMILY - Further details

What language is spoken at home?

Is an interpreter required?

YesNo

If yes, which language?

Is this a single parent household?

YesNo

Who else is directly involved in caring for the child, and what is their relationship to the child?

To your knowledge, has the child ever witnessed or experienced domestic violence or abuse?

Are our mentors or staff at risk of danger or abuse from family members, their associates, or animals at the home? If yes, please outline any risks.

RERERRER'S INFORMATION

Referrer's first name	Referrer's surname
Organisation making the referral	Referrer's role / job title
If Other, please state name of organisation or department	Referrer's Email
Referrer's Phone
School details
Name of primary school	Name of child's upcoming secondary school (if known)

Which professionals are working with this child/family? Please click yes if there are professionals involved and add their details here. NB if the referral is not coming directly from school, this must include a contact at the child's school.

OTHER PROFESSIONALS INVOLVED WITH CHILD OR FAMILY

First Name	Last Name (PLEASE NOTE - If you add professionals you must include a last name otherwise the submission of this form will fail).
Role	Name of school / organisation
Address (Street)	Address (City)
Post Code	Professional's Email
Phone

FURTHER REFERRAL INFORMATION

For referrals to the LIFT programme, please describe how this child meets at least one of the following criteria: disengagement or decreased attendance at school, social exclusion, risk of school exclusion, peer rejection or victimisation, area or postcode risk factors, is identified as at risk of serious violence, grooming, exploitation (criminal or sexual), or wider criminal networks, or who is growing up in a household where domestic abuse, parental separation, mental illness, alcohol abuse, or drug abuse is present, or where someone has been incarcerated.

Please outline your reasons for referring this child to Chance UK

What areas do you think the mentoring could work on, and what are yours and the family's best hopes for mentoring?

What are the child's activities and interests?

Please give details of current Social Care involvement here, and outline any past involvement or safeguarding concerns.

If the child is a Looked After Child - please specify:

	Yes	No	Don't Know
Does the child have any special educational needs or social, emotional and mental heath needs?
Does the child have either a Statement of Needs or an Education Health Care Plan? If yes, please attach below.
Does the child have Attention Deficit Hyperactivity Disorder (ADHD)?
Does the child have an Autistic Spectrum Condition (ASC) diagnosis?
Do you receive Pupil Premium funding for this child?
Does the child receive free school meals?

Please provide details of any Special Educational Needs or Social, Emotional and Mental Health needs.

Statement of Needs or Education Health Care Plan: if you have consent from the main carer to share this with Chance UK, please attach a copy of this.

Has the child been excluded from school?

If yes, when was this and for how long?

Is the child a young carer?

Does the child have CAMHS involvement (past or present)? Are they on the waiting list for CAMHS? If yes, please give details

MONITORING INFORMATION

The following themes are challenges faced by some of the families referred to Chance UK. These themes are monitored by Chance UK and do not determine whether a child is eligible for the mentoring programme.

What is the child's current school attendance percentage?

Has the child attended two or more primary schools since the age of 5? (Including attendance at a Pupil Referral Unit)

Are there any issues around mental health in the family?

Are there any issues around substance misuse in the family?

Is there any involvement of family members in the criminal justice system?

PRIVACY NOTICES

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?

Can Chance UK contact the family over the next 10 years to ask about you and your child's progress? This will really help us to understand what works best for the children and families we work with. If NO, we will anonymise all personally identifiable service information on our system after 2 years from completing or withdrawing from our service, and retain anonymous evaluations and reports under our Legitimate Interests.

How did you hear about the Mentoring programme. Please provide description in the text box.

Thank you for completing the referral!

For monitoring purposes, we will need to complete a Strengths and Difficulties Questionnaire with both the main carer and a teacher. We will be in touch to do this once the referral has been accepted.

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Contact Information

Referral form: LIFT, Safer Space, STEP, Westminster and Community Groups programmes

By consenting to this referral to Chance UK, the parent/carer is committing to take part in the support offered to parents and carers, that runs alongside mentoring. Please tick this box to confirm.

School details