This Joomla Template is equiped with JavaScript. Your browser does not support JavaScript! Please enable it for maximum experience. Thank you.
Please indicate the referring Local Authority and that this referral has been approved by the appropriate screening group and funding agreed.
Local Authority
Approved
Name
Position Held
Address
Telephone
Fax
Email
EDT Number
Active Ark will produce reports on a weekly basis.
Please indicate the preferred format and to whom the reports be addressed.
Weekly Report Format Email Postal
Email address for reports
Postal Address For Reports
Date Of Birth
Gender Please Choose Male Female
Reason For Referral Include young persons viewpoint.
Pen Picture For example – physical description, social skills, personality, interests, attitudes, anti-social behaviour, etc.
Previous Placement Details For example - Foster placements, specialist educational establishments, residential placements, level of supervision, reasons for placement changes.
Family Background For example family members, family dynamics including: ability to supervise/control young person's behaviour, parenting practices, quality of relationships, contact between parents and siblings or relevant persons
Challenging Behaviour Include specific details of offending history with and without charges, self harm, violent or aggressive behaviour, drug, alcohol or substance abuse, absconding, fire raising, sexually aggressive behaviour, bullying.
Educational History For example, previous schools attended and reasons for changes, level of achievement, school behavioural issues, relationships with peers and teachers, attendance, educational psychologist.
Educational Requirements or Needs
Other Agencies Involved Include previous and current involvement of agencies in relation to behaviours, for example: addiction workers, educational psychologists, specialist counseling.
Medical/Dental Issues
Medication
Previous GP Please provide Address, Post Code and Telephone
Special Dietary Needs
Special Needs
Religious Needs
Ethnicity
Allergies
First Language
Risk Assessment Please give details of the Young Persons most recent Risk Assessment. You can also upload the Risk Assessment below.
Risk Assessment Upload
Thank you text ?????????????.........
