Spark2Life Referral Form (Early Prevention)

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.

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* Date of Referral

Date

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* Name of School Provision

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* Date of Admission

Date

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* Type of Session

1:1 Mentoring Session

Group Sessions

One Off

None of the above

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* Session Start Date:

Date

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* Student's First Name

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* Student's Last Name

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

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* Year Group

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* D.O.B.

Date

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* Gender

Male

Female

Other

Prefer not to say

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* Ethnicity

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* EAL (English as an additional language)

Yes

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* SEN (Special Educational Need) Status

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.

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* If yes please give brief description:

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* LAC (Looked After Child)

Yes

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* Previously looked after Child

Yes

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* Pupil Premium (FSM)

Yes

Yes (Pupil Premium Plus)

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* Current School Attendance (%)

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* Current Amount of Fixed Term Exclusions

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* Previous School(s)

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* Name and position of person referring the young person

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* What is the reason for referral?

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* What is your end goal for this mentoring intervention?

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* Any Additional Comments?

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* Any Safeguarding Concerns?

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* Please select up to 5 focus areas of development

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)

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

Yes (Aware and agreed)

Yes (Just aware)