ADO River Valley Referral Form

ADO River Valley Education Referral Form

Please Complete the Form With As Much Detail As Possible.

Fields Marked (*) Must Be Completed

If The Form Does Not Send At The End, Check All The Fields Have Been Completed. Scroll To The Top, Complete The Field With The Error and Then Try Re-Sending

This Form Has Been Tested On All Popular Computer Browsers and Devices. Please DO NOT Complete on Any Mobile Smart Devices or Phones.

THIS FORM CANNOT BE PART SAVED SO PLEASE ENSURE YOU HAVE ALL THE DETAILS TO HAND TO COMPLETE THE FORM. PLEASE ALSO MAKE SURE YOUR INTERNET CONNECTION IS STABLE BEFORE YOUR START.

Referrer Details

Name:(*)

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Telephone:(*)

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Job Title:(*)

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E-mail:(*)

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Agency:(*)

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Date of Referral:(*)

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How long have you worked with the Young Person? (Please tick)(*)

Less than 6 months6 months to 1 year1-2 yearsMore Invalid Input

In what capacity? (Please tick)(*)

Local AuthorityTeaching Professional/Current SchoolCAMHSFostering AgencySocial WorkerOther (Please Specify) Invalid Input

If Other Please Specify Here

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Long Term Placement(1 year - Full Education duration, which could include Post-16)

Student Details:

Student’s UPN (if known):

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Student’s ULN (if known):

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Which educational qualifications is the student interested in? (Please note that this service is designed for KS4-Post16 and the below courses can be applied dependent on academic and emotional ability to each individual student.)(*)

Animal Care: (AQA Awards or BTEC)Equine Studies: (AQA Awards or BTEC)Countryside & Environment: (AQA Awards or BTEC)Sport Activity & Fitness, Sport Leadership, Outdoor Sport (AQA Awards or BTEC)Youth & Healthcare (AQA Awards or BTEC)Business Studies (AQA Awards or BTEC)Functional Skills (Maths/English/ICT): Entry Levels 1/2/3, and Level 1 and 2 Invalid Input

Our model provides a combination of Cognitive Behaviour Therapy, Relaxation Therapy, Animal Therapy and Occupational Therapy to suit the needs of each individual and support the students’ wellbeing.

Would this student benefit from any specific embedded therapeutic workshops to increase their emotional resilience, well-being and coping skills? (*)

YesNoUnsure Invalid Input

If ‘yes’, please tick below which ones;

Managing StressManaging AngerManaging AnxietyDeveloping Social SkillsManaging Depression Invalid Input

In your view, would you like the student to have access to 1:1 Outcome Therapy sessions within their timetable when on site with us? (Please note it is not suggested for individuals to have therapy sessions with us if they are already accessing this from another provider such as CAMHS)(*)

YesNoNot Sure Invalid Input

Emergency Contact Details for the Student

Name:(*)

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Relationship:(*)

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Mobile Telephone:(*)

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(We use SMS or telephone calls to keep parent-carers up to date on their child/yp as required so please provide a phone number where permission is granted for both SMS and calls during the school day)

E-mail: (*)

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If the parent/carer that resides with the child/yp has any known additional needs or any information we should be aware of in order to support the family when liaising with them about their child/yp, please detail this here:

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Assessment

BILLING INFORMATION:

Who will be funding the assessment/placement(*)

Local BoroughSchoolOther Invalid Input

If Other Please Specify:

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Invoicing Contact Name:(*)

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Invoicing Contact Job Role:(*)

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Invoicing Contact Phone Number:(*)

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Invoicing Email Address for E-Billing:(*)

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Invoicing Client Address for System Purposes:(*)

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Please Note: All billing fields require completion for system setup and assessments to be booked.

The assessment consists of the completion of this online referral form prior to us meeting the individual. This is classed as ‘Stage 1’ of our assessment process, followed by ‘Stage 2’ which is a two day practical assessment.

Practical Assessment

(Maximum two adults; recommended one professional and one parent-carer).

The supporting adult/adults will be required for the first 2 hours of the first day assessment. If the student settles within this time, the student is able to remain on site until the end of the school day. This allows staff to assess engagement and affirm we can safely meet their needs in the outdoor setting, before meeting them again for the second day.

Adult 1 (Required)

Name(*)

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Relationship/Role:(*)

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Telephone:(*)

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E-mail:(*)

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Adult 2

Name

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Relationship/Role:

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Telephone:

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Email:

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ADO River Valley Education Referral Form

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