This is an Old Survey, PLEASE DO NOT USE!!!!

Criteria for referral

The criteria for the mentoring within schools is as follows:

Misunderstood behaviour
· Low self-esteem
· Disruptive actions
· Physical and/or verbal aggression
· Risk-taking tendencies (involve decision making that involve potential danger, or the possibility of negative consequences.)

Academic frustration

· Poor attendance and/or punctuality
· Frequent truanting
· Negative attitude toward school and learning
· Underachieving

Internal/Fixed Exclusion

· Behaviour points
· Report
· Regular detentions

Nb. All referrals are subject to assessment by the Spark2Life School's Coordinator to see if they meet the criteria.

PLEASE NOTE

Please fill in the referral form with as much information as possible. If there are any issues with the form please contact emmanuel.j-o@spark2life.co.uk or contact our head office on 0204 531 6208 and ask for Emmanuel Joe-Ofili.

Question Title

Date of Referral (Required.)

Date

Question Title

Name of School Provision (Required.)

Question Title

Date of Admission (Required.)

Date

Question Title

Type of Session (Required.)

1:1 Mentoring Session

Group Sessions

One Off

None of the above

Question Title

Session Start Date: (Required.)

Date

Question Title

Student's First Name

Question Title

Student's Last Name

Question Title

Student's preferred name (if different from their First Name)

Question Title

Year Group (Required.)

Question Title

D.O.B. (Required.)

Date

Question Title

Gender (Required.)

Male

Female

Other

Prefer not to say

Question Title

Ethnicity (Required.)

Question Title

EAL (English as an additional language) (Required.)

Yes

Question Title

SEN (Special Educational Need) Status (Required.)

E - Education, Health and Care Plan (EHCP): The pupil has a formal EHC plan in place, a legal document outlining their needs and the provision required.

K - SEN Support: The pupil receives SEN support from the school but does not have an EHC plan. Previously known as "School Action" or "School Action Plus".

N - Monitoring: The pupil is not identified as having SEN; however, school are monitoring due to parental and/or professional curiosity.

N - No Special Educational Need: The pupil is not identified as having SEN.

Question Title

If yes please give brief description:

Question Title

LAC (Looked After Child) (Required.)

Yes

Question Title

Previously looked after Child (Required.)

Yes

Question Title

Pupil Premium (FSM) (Required.)

Yes

Yes (Pupil Premium Plus)

Question Title

Current School Attendance (%) (Required.)

Question Title

Current Amount of Fixed Term Exclusions (Required.)

Question Title

Previous School(s)

Question Title

Name and position of person referring the young person (Required.)

Question Title

What is the reason for referral? (Required.)

Question Title

What is your end goal for this mentoring intervention?

Question Title

Any Additional Comments? (Required.)

Question Title

Any Safeguarding Concerns? (Required.)

Question Title

Please select up to 5 focus areas of development (Required.)

Substance Misuse

Relationships with friends

Physical appearance

Conflict Resolution

Punctuality and Attendance

Youth violence/gangs

Emotional Intelligence

Consequences (Peer Pressure)

Perceptions of Women

Overall Mental Health

Self-esteem

Self-control

Communication

Exclusions/FTEs

Aspirations (Career Prospect/Long term thinking)

Question Title

The family are aware and have agreed for the young person to work with Spark2Life (Required.)

Yes (Aware and agreed)

Yes (Just aware)

This is an Old Survey, PLEASE DO NOT USE!!!!

Criteria for referral

Question Title

* Date of Referral (Required.)

Question Title

* Name of School Provision (Required.)

Question Title

* Date of Admission (Required.)

Question Title

* Type of Session (Required.)

Question Title

* Session Start Date: (Required.)

Question Title

* Student's First Name

Question Title

* Student's Last Name

Question Title

* Student's preferred name (if different from their First Name)

Question Title

* Year Group (Required.)

Question Title

* D.O.B. (Required.)

Question Title

* Gender (Required.)

Question Title

* Ethnicity (Required.)

Question Title

* EAL (English as an additional language) (Required.)

Question Title

* SEN (Special Educational Need) Status (Required.)

Question Title

* If yes please give brief description:

Question Title

* LAC (Looked After Child) (Required.)

Question Title

* Previously looked after Child (Required.)

Question Title

* Pupil Premium (FSM) (Required.)

Question Title

* Current School Attendance (%) (Required.)

Question Title

* Current Amount of Fixed Term Exclusions (Required.)

Question Title

* Previous School(s)

Question Title

* Name and position of person referring the young person (Required.)

Question Title

* What is the reason for referral? (Required.)

Question Title

* What is your end goal for this mentoring intervention?

Question Title

* Any Additional Comments? (Required.)

Question Title

* Any Safeguarding Concerns? (Required.)

Question Title

* Please select up to 5 focus areas of development (Required.)

Question Title

* The family are aware and have agreed for the young person to work with Spark2Life (Required.)

Date of Referral (Required.)

Name of School Provision (Required.)

Date of Admission (Required.)

Type of Session (Required.)

Session Start Date: (Required.)

Student's First Name

Student's Last Name

Student's preferred name (if different from their First Name)

Year Group (Required.)

D.O.B. (Required.)

Gender (Required.)

Ethnicity (Required.)

EAL (English as an additional language) (Required.)

SEN (Special Educational Need) Status (Required.)

If yes please give brief description:

LAC (Looked After Child) (Required.)

Previously looked after Child (Required.)

Pupil Premium (FSM) (Required.)

Current School Attendance (%) (Required.)

Current Amount of Fixed Term Exclusions (Required.)

Previous School(s)

Name and position of person referring the young person (Required.)

What is the reason for referral? (Required.)

What is your end goal for this mentoring intervention?

Any Additional Comments? (Required.)

Any Safeguarding Concerns? (Required.)

Please select up to 5 focus areas of development (Required.)

The family are aware and have agreed for the young person to work with Spark2Life (Required.)