Chance UK Referral Form

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This form is part 1 of a 2 part referral form for Chance UK's Explore & Empower family service in Islington. 
Explore & Empower is a support service for families with children who display challenging behaviour.
Part 1 below will establish basic eligibility. Part 2 will ask for details about the family and how we may support them.

Newly referred families, with a child meeting our behavioural threshold are entitled to access: 

Ÿ   Children will receive up to 9 months of input from a Chance UK mentor and staff. 
Ÿ   Children will begin sessions remotely during lockdown. Physical 1:1 sessions in the community is the aim for all mentoring relationships, but only once it is safe for all to do so.
Ÿ   Parents and carers will have 1:1 support and group options from our Family Support team.
Ÿ   Chance UK Programme Managers will provide remote contact with the child before they can be matched with a mentor.
Ÿ   With Chance UK’s support, children and mentors will identify the child’s strengths, use solution-focused talking tools to improve issues, and make and complete goals. Families will review and support these changes and progress, have support to access group work from Chance UK as well as the option of accessing support from other organisations. 
Ÿ   Families will graduate from the programme in spring 2021. After this, all contact between the family and the mentor will stop after graduation. 

ELIGIBILITY QUESTIONS




CHILD









REFERRER











SCHOOL OR OTHER PROFESSIONAL BEHAVIOURAL ASSESSMENT
Goodman Strengths and Difficulties Questionnaire (SDQ)
Copyright Robert Goodman 1997. Permission granted for use.
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.


Not True Somewhat True Certainly True
MAIN CARER BEHAVIOURAL ASSESSMENT
Goodman Strengths and Difficulties Questionnaire (SDQ)
Copyright Robert Goodman 1997. Permission granted for use.
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.


Not True Somewhat True Certainly True