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ACTIVATE YOUNG PERSON REFERRAL FORM

In order to undertake any service with Activate Body and Mind we ask all potential referral contacts to complete the following Young Person Referral Form, in detail, so we can get a better insight into the reason for referral.

Once we have received the form and requirements have been assessed, we will then respond within 7 working days

DETAILS OF YOUNG PERSON BEING REFERRED
EMERGENCY CONTACT DETAILS 1
EMERGENCY CONTACT DETAILS 2
REFERRER DETAILS
BACKGROUND HISTORY
ACCOMMODATION STATUS
CONCERNS OF EXPLOITATION

If there is an EHCP in place currently, please email it in the strictest confidence to info@activatebodyandmind.co.uk

Gender
Is the young person currently attending school?
Does the young person have a disability?
Does the young person have a Mental Health diagnosis?
Is the young person known to CAMHS or another mental health service?
Is there currenly a signed parental declaration relating to the home school agreement?
Is there an EHCP in place currently?
YOUNG PERSON REFERRAL DETAILS
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