Initial Referral Form

Please complete this form to provide information about a young person (including yourself) you believe meets the US eligibility criteria and who would benefit from US’s support to access sport and exercise to improve their wellbeing.

Young Person's (Your) Contact Details

First Name*

Last Name*

Telephone Number*

Email address

Address

Postcode

Where is this home address?

Newcastle

North Tyneside

Gateshead

Sunderland

South Tyneside

Northumberland

Durham

Other

Is the young person aware of and agreeable to this referral?

Yes

Is the young person over 18?

Yes

Preferred means of first contact

Call / Text / Email?

With Who?

Young Person (You)

Parent / Carer

Parent / Carer's Details (if young person under 18)

Parent / Carer's Name

Parent / Carer's Telephone Number

Parent / Carer's Email address

Is the Parent / Carer's address the same as that of the young person above?

Yes

Don't Know

Parent / Carer's address

About the Young Person (You)

Date of Birth*

Age*

Gender

Ethnicity

Disability

Yes

Please give details:

School / College / Place of work

Safeguarding Status:

CAF/ TAC/ TAF/ Early Help

Child in Need

Child Protection

Vulnerable Adult

None

Not Known

Other Agencies Supporting or working with you / the young person:

Young Person's (Your) Details

Please tick as appropriate. One tick will indicate that the young person meets the US participant criteria. If you do not wish to provide specific details within the referral, tick the last box.

Educated in school for young people with Social and Emotional needs

Diagnosed mental illness

Experiences depression

Experiences anxiety

Autistic Spectrum Disorder

ADHD

Exhibits social anxiety

Low self-esteem

Difficulty forming positive relationships

Exhibits anti-social or problematic behaviour

Is a Looked After Child or at risk of going into care / Care Leaver

Is a refugee/asylum seeker

Is a young carer

Experiences or is at risk of developing mental health issues

Preferred types of activities with US?

Small Group

One to One

Support to access community activities

Online

What activities would be of interest?

Any specific support needs?

For example, communication needs, reasonable adjustments, independent travel.

Keeping you / the young person safe during activities

Please tick any of the risks below which relate to you / the young person:

No Known risk

At risk of adult abuse

At risk due to disability

At risk due to mental health

At risk of self-neglect

At risk of self harm

At risk of suicide

At risk of exploitation

At risk of radicalisation

At risk of domestic violence / abuse

Risk to children

Risk of violence / harm to others

Risk to staff

Please provide details:

For any risks identified please provide details of these risks, including current risk management strategies.

Referrer's Details

Which of these best describes you?

The young Person

Parent / Carer

Professional / Agency

Referrer Name*

Referrer Job Title / Organisation (If professional / agency worker)

Referrer's Email address *

Referrer's Telephone No. *

Next Steps

Once submitted, this form will be emailed to the [email protected] mailbox.

A member of the US team will contact you to discuss this referral.

The US team will contact either the young person (you) or (your) parent / carer in the preferred way stated above.

If there will be a delay in progressing your referral, we will inform you and give an expected timescale.

Agreements

US values your privacy and is committed to protecting your data. This information will be held securely on computer and within manual files. As a data processor we are registered with the ICO and committed to meeting the requirements of GDPR. The personal information we collect from you will mainly be used by our staff (and volunteers) at US so that they can deliver our activities and provide the best support to the young person. We will never sell or share personal information with organisations so that they can contact you for any marketing activities. US may share your information with our trusted partners and suppliers who work with us or on our behalf to deliver our services, with other groups or agencies for continuation of or new support for young people, and with bodies who have provided funding for our work with this and other young people. We may disclose your information if required to do so by law (for example, to comply with applicable laws, regulations and codes of practice or in response to a valid request from a competent authority)

- I acknowledge and consent to the above personal information handling and sharing

- I give my consent for US to use the information I have provided to offer information, advice and support to the young person named.

Signature of Referrer

I give my consent for this information to be shared with US.

Please type your name here

27/04/2024

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