Activity on referral programme

This form starts the process to support an early intervention programme using physical activity to support a young persons mental wellbeing.

Please note:

Due to the high volume of referrals we are currently receiving, it may take up to 3 weeks from the date this form is received for the young person and their family to receive contact from us.

Referral Process

This form should be completed by a education or social work professional with consent from parents. We hold this data for a period of 12 months and then review if we need to retain it any further based on a young person still being within the programme. Information is either deleted after this review or retained for a further 12 months. Active Gloucestershire co-ordinator liaises with referrer and family to let them know of the upcoming programmes and to book their place on a suitable activity session.

Please note that all sections must be completed as this form is an important data collection and risk assessment tool. Regrettably, we will be unable to process referral forms with incomplete sections.

Information for referrers

The sessions offered are with local providers and each young person is eligible for 12 sessions. We will pass over a small amount of information to an activity provider in order to book the young person into the session. They may have their own forms to complete too.

Referral criteria: The young person (primary or secondary age young people) being referred is seen by the referrer to be experiencing anxiety, stress or low mood. Outcomes we typically expect from these programmes: 1. Increased social connection 2. Develop emotional resilience through engagement with physical activity 3. Decrease in anxiety, stress and low mood 4. Learning how to use physical activity to support positive mental health beyond the session

Our first contact attempt is made via email. Please indicate below if this is suitable.

Select

Today's Date*

Section One

Referred person's details (all areas to be completed with person being referred /parent/carer)

Name*

Date of Birth*

Name of parent / carer*

Contact email*

This will be the address we contact to arrange sessions

Contact phone number*

Referred person's address*

Postcode*

Reason for referral*

Please describe the difficulties and the impact they have on the young person

Potential outcomes for being more active*

What would the young person like get out of the sessions.

Additional access / support needed*

Please tell us how to support this young person to successfully access the activity. This may include medical needs.

Current activity level and preferences*

Please tell us more about this young persons activity level - how often to they take part in activities outside of the school curriculum and do they enjoy any particular sport or activity. Please also state if there is something they would not like to take part in.

Activity Choices

Below you will see a list of activities currently available on the programme.

Please select those that this young person finds most appealing. Occasionally we're able to accommodate other activities.

If you are referring a young person from one of the new districts, this field can be left blank.

Select or enter value

Section Two

Referrer’s details (to be completed by referrer)

Referrer's name*

Referrer's role*

Referrer's email address*

This will be the address we contact to arrange sessions

Referrer's contact number*

School*

The school the young person attends

Select

Primary / Secondary

Select or enter value

Year Group*

Select or enter value

Mental Health Lead *Name

Mental Health Lead *email adress

Section Three

Consent - (to be completed by referred person and/or parent/carer)

Evaluation consent*

Understanding and evaluating the impact of the programme is an important part of this project. We will be asking professionals, parents and young people to provide feedback. Please confirm by ticking the box that the young person and their family give consent for their information to be shared with Active Gloucestershire's evaluation partners.

Information sharing consent*

I understand that the information contained in section one will be passed on to the activity provider in order to book a young person into their session.

Send me a copy of my responses

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