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Referral Form

All referral forms must be completed in full. If a young person is excluded, you can email the Annex G to info@southwestap.co.uk instead of completing this form.

1.   REFERRAL

2.   YOUNG PERSONS' DETAILS

3.   PERSON WITH PARENTAL RESPONSIBILITY

4.   REASON FOR REFERRAL

5.   KEY RISKS & MITIGATION MEASURES

6.   YOUNG PERSONS PROFILE

ATTENDANCE / PUNCTUALITY
PoorFairGoodVery goodExcellent
RESPECT
PoorFairGoodVery goodExcellent
CONFIDENCE
PoorFairGoodVery goodExcellent
INTERACTION WITH OTHER STUDENTS
PoorFairGoodVery goodExcellent
INTERACTION WITH TEACHERS
PoorFairGoodVery goodExcellent
GENERAL BEHAVIOUR
PoorFairGoodVery goodExcellent
ATTITUDE TO HOME LIFE & CURRENT SITUATION
PoorFairGoodVery goodExcellent
RESPONSIBILITY
PoorFairGoodVery goodExcellent
PARENTAL ATTITUDE
PoorFairGoodVery goodExcellent
ENTHUSIASM
PoorFairGoodVery goodExcellent
SOCIAL AWARENESS
PoorFairGoodVery goodExcellent
SELF-CONTROL
PoorFairGoodVery goodExcellent

7.   SOCIAL PROFILE

OTHER AGENCY INVOLVEMENT (tick all that apply)
DOES THE YOUNG PERSON FALL INTO ANY OF THESE GROUPS

8.   ATTENDANCE REQUIREMENTS

To give us an idea of what provision you are looking for, please let us know what days you are looking for and for how long.

PROVISIONAL DAYS
TERMS

It is vital that any referral is accompanied by targets for South West AP to focus on with the Young Person. It can be attendance, language, choice making, behaviour etc. Keep the targets simple and achievable, these can be reviewed.

Thank you for completing the referral form. If you have any supporting documentation that you think will be of value, please email this to info@southwestap.co.uk.

We will contact you within 48 hours to discuss the young person and the next steps in helping them on their next journey.

THANK YOU FOR SUBMITTING THE REFERRAL

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