Full Circle Referral Form

This form is to be used by professionals seeking to refer a young person to the Full Circle Education Training Programme. We offer a structured three day a week provision with alternative accreditation opportunities. A funding commitment MUST be agreed between the referring agency and Full Circle Education, and this will be discussed once the referral has been agreed in principle. See our website www.fullcircleeducation.com for more information about our programme.

Referring Agency Details Date of Referral:

_______/_______/_______

Name of Referring Agency: Address:

_________________________________________ _________________________________________ _________________________________________ _________________________________________

Name of Referring Contact:

_________________________________________

Position Within Organisation:

_________________________________________

Telephone Number/s:

Work:____________________________________ Mobile:___________________________________ _________________________________________

E-mail Address: Young Person Details Name of Young Person:

_________________________________________

Gender:

Male (

Name of Parent / Guardian:

_________________________________________

Address:

_________________________________________ _________________________________________ _________________________________________

Home Telephone Number: Mobile Telephone Number:

_________________________________________ _________________________________________

Date of Birth:

———/———/———-

Academic Year Group:

Year 10 ( )

Year 11 ( )

Is the young person eligible for free school dinners?

Yes (

No (

)

)

Female (

)

Age:_______________

)

Referral Information (1) Why are you referring this young person to ‘Full Circle Education’?

Please tick all that apply in each section, and provide ALL additional and relevant information either: A. In the box provided below each section OR B. As attached documents from the young person’s file

School Factors 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

At Risk of Temporary/ Permanent Exclusion Has already been temporarily excluded (Please provide details) Persistent disruptive behaviour in the classroom Failure to follow instructions Rudeness and abuse towards staff and others Not entered for GCSE’s Moderate Learning Difficulties Low Level Literacy/Numeric Statemented Non-attendance to school School Phobic Regular Truancy Other Reasons:_____________________________________________

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Please expand and give any additional and relevant information about the young person here:

Social/ Family/ External Factors 1. 2. 3. 4. 5. 6. 7. 8. 9.

Known or suspected involvement in anti-social behaviour Has been arrested (please provide details) Substance abuse (alcohol, drugs etc.) Friends, siblings or family in trouble with the police History of violence/ abuse in the family Problems at home Problems with health (mental, emotional, physical) Young Person is on the Child Protection Register Other ______________________________________________________

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Please expand and give any additional and relevant information about the young person here:

) ) ) ) ) ) ) ) )

Referral Information (2) How long and in what capacity have you known this young person?

Is the young person being referred currently on any other alternative programmes or schemes?

Full Circle Education only offers a three-day a week training programme on Monday, Wednesdays and Fridays. What educational provision will be made for the young person on the Tuesdays and Thursdays? School : Negotiated Timetable Home Study Alternative Training Work Experience Other

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Will the young person being referred be entered for any qualifications (e.g. GCSE, GNVQ, BTEC)? Yes (

)

No ( )

If Yes, please indicate below those which he/she will be entered for:

Please enter any other relevant information about the young person including their: A. Strengths & Achievements B. Skills C. Specialist Interests D. Additional Needs & Specific Requirements

Referral Information (3) Ethnic Group (A) White 1. White British (including white English, Scottish or Welsh or mix of these) 2. White Irish 3. Any Other White Background Please State________________________________________ Ethnic Group (B) Mixed 1. White and Asian 2. White and Black African 3. White and Black Caribbean 4. Any other Black Background Please State _________________________________________ Ethnic Group (C) Asian or Asian British 1. Bangladeshi 2. Indian 3. Pakistani 4. Any other Asian Background Please State _________________________________________ Ethnic Group (D) Black or Black British 1. Black African 2. Black Caribbean 3. Any other Black Background Please State _________________________________________ Ethnic Group (E) Chinese and Vietnamese 1. Chinese 2. Vietnamese

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Ethnic Group (F) Other Please State:________________________________________________ Please Return the completed form to: Damon Moore—Project Manager Full Circle Education The Samuel Montagu Centre 126 Broadwalk Kidbrooke London SE3 8ND Tel/Fax: 0208 8562050 Mobile: 07834 156482 E-mail : [email protected]

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