ALP: Small Group/ Transitions Programme Offer Referral

Please tick which is appropriate for your referral: (required)

I am making a request for small group programme to be delivered in my schoolI am making a request for the transitions programme to be delivered in my school

Referrer’s Name (required)

Relationship to young people (required)

Referrer’s telephone (required)

Referrer’s mobile

Referrer’s email

Referrer’s contact address

Year group being referred to the programme

Contact details of main point of contact for that year and group (if different from referrer) - include name/email/phone number

Number of students being referred (maximum of 10):

Reason for referral

Group experience - are the individuals in the group experiencing any of the following (tick all that apply) (required)

Sexual abuseEmotional abuseLiving with someone who abused drugsLiving with someone who abused alcoholExposure to domestic violenceLiving with someone who was incarceratedLiving with someone with serious mental illnessParental loss through divorce, death or abandonmentAsylum seeker or refugeeWellbeingPhysical HealthSexual HealthOther

Please provide details if applicable (if OTHER, please explain here))

Details of any LDD or other disability within the group

If a known activity would be beneficial for the group, please highlight below (tick all that apply):

DanceSpoken wordCreative writing (including lyric writing)Circus skillsDramaArtGraffiti/ Mural ArtMusic - live or productionTextiles/ fashionPhotographyFilmSong writing

If requesting the small group programme, how many programmes of 16 week delivery are you requesting?

Additional information for Transitions Programme

Please provide the names of the primary schools that would be the feeder schools for this referral (up to 10 schools)