Chloe's Connections Group

Introduction to Programme?:
How did they come to be referred onto the project/How did you come to hear about the project?

Young Person’s first name:

Young Person’s surname:

Young Person’s Email Address:

Young Person’s phone number:
Please use this to provide the contact number for the participant – this will be used to share information about sessions and activities.
Please note that we will ask them for their permission to use this alongside this form.

Young Person’s date of birth (DD/MM/YYYY):

Young Person’s ethnicity:
Asian/Asian British – ChineseAsian/Asian British – PakistaniAsian/Asian British – IndianAsian/Asian British – BangladeshiAsian/Asian British – OtherAsian/Asian British – (Unspecified)Black/African/Caribbean/Black British – AfricanBlack/African/Caribbean/Black British – CaribbeanBlack/African/Caribbean/Black British – OtherBlack/African/Caribbean/Black British – (Unspecified)Mixed/multiple ethnic groups – White and AsianMixed/multiple ethnic groups – White and Black AfricanMixed/multiple ethnic groups – White and Black CaribbeanMixed/multiple ethnic groups – OtherMixed/multiple ethnic groups – (Unspecified)White – Welsh/English/Scottish/Northern Irish/BritishWhite – IrishWhite – Gypsy or Irish TravellerWhite – OtherWhite – RomaWhite – (Unspecified)Other ethnic group – ArabOther ethnic group – OtherPrefer not to sayNot Disclosed>

Young Person’s gender:
FemaleMaleNon-BinaryOtherPrefer Not to Say

Young Person’s post code:
We use this information to understand where everyone is based for travel/access to sessions.

School Year/College Year:

Name of School:

School Contact:
Please add in the name and contact details (if known) of who we can contact at the school to let them know about upcoming dates for the project

Parental/Guardian consent:
Please indicate if the parent/guardian of this young person is aware of and gives consent to this referral.
If they are not aware, please give some indication as to why in the any other information section.
YesNoNot Applicable as over 18

Emergency Contact Name:
Please give the name of an emergency contact and the nature of their relationship. i.e. Sarah – Sister.

Emergency Contact Number:
Please include the number for the emergency contact

Parent/guardian email address:

Reason to make a referral?:
Please select all that apply.

Do they have a SEND diagnosis or an EHCP?:
If YES, please use the further information box at the end of the form to share details.
YesNoUnsure

SEND – Further information:
Please use this box to record their SEND, if not available please write ‘Not Disclosed’

Any further information?:
Please use this box to give any further information that would be helpful to understand the reasons for referral. i.e. ‘would benefit from peer support’ or ‘has expressed concerns about their mental health previously’