All Questions on Pages 1-3Are Mandatory.Additionally;

Venture Trust

Referral Form

Please return completed ReferralForms to your local Venture Trust worker
Contact details for each hub can be found on our website:

All questions on pages 1-3are mandatory.Additionally;

-If the candidate you are referring has had any involvement with the Criminal Justice system, please complete the relevant section on pages 4-5.

-If the candidate you are referring has served in the Armed Forces (for any length of time), please complete the relevant section on page 6.

Referrer’s Declaration:

Information on this form may be used as evidence to demonstrate the candidate’s background/situation.

Please sign and dateby hand upon completion to declare that the information you have provided is correct, to the best of your knowledge and that the candidate has a legal right to live and work in the UK.

Referrer’s Name: / Click here to enter text. / Date:
Referrer’s Signature: / It is a mandatory requirement for you to sign this document BY HAND

CANDIDATE DETAILS

DETAILS OF PERSON BEING REFERRED / Evaluation Code(VT office use only)
Full Name:
Please detail any name changes / Click here to enter text. / Candidate’s Address: / Click here to enter text. /
Date of Birth: / Click here to enter text. / Postcode: / Click here to enter text. /
Gender: / Click here to enter text. / Local Authority: / Click here to enter text. /
National Insurance Number:If known / Click here to enter text. / Does the candidate have a bank account? / YES / ☐ /
NO / ☐ /
Mobile Number: / Click here to enter text. / UNKNOWN / ☐ /
Other Number: / Click here to enter text. / If yes, which bank? / Click here to enter text. /
ADDITIONAL INFO: / Email Address: / Click here to enter text. /
Please use the box below to note any important medical information, or any other issues not covered elsewhere on this form, which may affect participation in our Programmes
Please note that pregnancy would usually rule out a referral
Click here to enter text.

LEAD REFERRER DETAILS

Referral Route
(please mark ‘x’ for one only) / Court / ☐ / Notes / Click here to enter text. /
Partner Agency
(including Veteran org. or charity) / ☐ /
Prison/YOI / ☐ /
School/Education Unit/College / ☐ /
Self-referral / ☐ /
Social Housing/Foyers / ☐ /
Social Work (including SDS) / ☐ /
Date of Referral: / Click here to enter text. / Office Address: / Click here to enter text. /
Referrer’s Name: / Click here to enter text. /
Job Title: / Click here to enter text. / Postcode: / Click here to enter text. /
Email address: / Click here to enter text. /
Organisation: / Click here to enter text. /
Phone Number: / Click here to enter text. / Fax Number: / Click here to enter text. /
Out of hours/stand by contactnumber (to be used in an emergency only): / Click here to enter text. /

CANDIDATE’S SITUATION

PLEASE TICK ONLYONE OF THE FOLLOWING 5 EMPLOYMENT STATUSES:

1. Unemployed: Without work and in receipt of JSA

/ ☐ / 4.Economically Inactive:Not employed andnot registered as unemployed e.g. full time students / ☐ /

1. Long Term Unemployed: As above, continuously for >6months (under 25 years) or >12 months (over 25 years)

/ ☐ / 5.In formal Employment: / ☐ /
If you have selected ‘In Formal Employment’, please provide further info: / Full Time: / ☐ /
Part Time: / ☐ /

1. Inactive:Not part of labour market and not in training or education

/ ☐ / Self Employed: / ☐ /
Employer and Job Title: / Click here to enter text. /
PLEASE ANSWER THE FOLLOWING QUESTIONS, TO THE BEST OF YOUR KNOWLEDGE:
6. / If applicable, how long has the candidate been signing on at the job centre?Please tick the appropriate box: / Between 1 day – 6 months / ☐ /
Between 6 months – 1 year / ☐ /
Between 12 months – 2 years / ☐ /
Between 24 months – 3 years / ☐ /
Over 3 years / ☐ /
Unknown / ☐ /
7. / Is the candidate in receipt of any other benefits?If yes, please list.Evidence of additional benefits may be required / Click here to enter text. /
8. / How long since the candidate: / a)Completed education/training? / Give timeframe in months/years. /
b)Left a job? write n/a if neverworked / Give timeframe in months/years. /
9. / What is their highest current qualification level?
e.g. Standard Grade/National 4/SCQF 4 / Click here to enter text. /
PLEASE PLACE AN ‘X’ NEXT TO ALL THAT APPLY TO THE CANDIDATE:
NEET Aged 16-19 / ☐ / Previously Offended 1 / ☐ /
At risk of becoming NEET upon leaving school / ☐ / Criminal Record 1 / ☐ /
Low Skilledqualifications ≤ SCQF 5
Skilled / ☐ / Armed Forces Veteran/Currently Serving2 / ☐ /
No experience of paid work / ☐ / Registered Disabled / ☐ /
Leaving/Currently in Care Looked after children (at home or away from home), including those leaving care up to and including the age of 25 / ☐ / Long Term Physical Illness/Condition
‘Substantial’ and ‘long-term’ negative effect on their ability to do normal daily activities;Includes those considered to be disabled but who are not registered as such / ☐ /
Caring ResponsibilitiesPrimary Carer / ☐ / Literacy or Numeracy Problems / ☐ /
Lone Parent / ☐ / Learning Disability / ☐
Living in a Jobless Household / ☐ / Mental Health Issues / ☐ /
Homeless or affected by housing exclusion rooflessness, houselessness insecure accommodation/inadequate housing / ☐ / History of Substance Dependency / ☐ /
History of Alcohol Dependency / ☐ /

1. Please complete ‘Candidate’s Justice Information’ questions on pages 4-5, for any offending behaviour
2. Please complete the ‘Armed Forces information’ section on page 6

CANDIDATE’S AREAS FOR PERSONAL DEVELOPMENT

Identified by the referrer

Venture Trust typically offersthree phase personal development and early stage employability programmes, centred on an intensive wilderness based personal development journey.

Our programmes have been proven to enable participants to develop in the areas listed below; please select up to 3 out of the 5 main categories, and any relevant subcategories which you think are most pertinent for the candidate you are referring, by placinga tickin the right hand column.

1. Improve their self-confidenceplease tick all applicable sub categories

/ ☐ /
-Confidence to share ideas / ☐ /
-Confidence to represent views in a positive manner / ☐ /
-Confidence to give and receive feedback / ☐ /
-Confidence to ask for help / ☐ /
-Confidence to accept the opinion of others / ☐ /

1. Improve their employabilityplease tick all applicable sub categories

/ ☐ /
-Ability to set clear goals / ☐ /
-Motivation to attain/work towards goals / ☐ /
-Motivation to learn new skills / ☐ /
-Ability to deal with change / ☐ /
-Self-Care including eating properly, getting enough sleep, hygiene / ☐ /
-Time management / ☐ /
-Personal Responsibility for behaviour, self and actions / ☐ /

1. To stabilize their lives/reduce risk of (re-)offendingplease tick all applicable sub categories

/ ☐ /
-Peer Influence involvement with negative peers and associated behaviour / ☐ /
-Drug/Alcohol misuse / ☐ /
-Attitudes towards crime/anti-social behaviour / ☐ /
-Accommodation / ☐ /

1. Improve their relationships with others

/ ☐ /

1. To make better use of local services and opportunities

/ ☐ /
PLEASE COMMENT FURTHER ON THE AREAS IDENTIFIED ABOVE
Click here to enter text.

CANDIDATE’S JUSTICE INFORMATION

SCRO NUMBER(if applicable): Provision of SCRO number is a requirement of the Scottish Government in order to track re-offending rates / Click here to enter text. /
RISK ASSESSMENT INFORMATION Provision of risk assessment information is essential
Risk Assessment Framework Used: / Click here to enter text. /
Risk to community (aka risk of reoffending) / LOW / MEDIUM / HIGH
☐ / ☐ / ☐ /
Risk to self (aka risk of harm) / ☐ / ☐ / ☐ /
Is the candidate you are referring subject to a Probation Order?(please mark ‘X’ in appropriate box) / YES / ☐ /
NO / ☐ /
Is the candidate you are referring subject to a Community Payback Order?(please mark ‘X’ in appropriate box) / YES / ☐ /
NO / ☐ /
Is the candidate you are referring subject to any other orders?(please mark ‘X’ in appropriate box)(E.g. Drug Treatment & Testing Order (DTTO), Restriction of Liberty Order (RLO), Home Detention Curfew (HDC), parole, other?) / YES / ☐ /
NO / ☐ /
If yes, please state which orders: / Click here to enter text. /
IF YES TO ANY OF THE ABOVE, PLEASE GIVE THE FOLLOWING INFORMATION:
Main offence: / Click here to enter text. /
Type of offence: / Click here to enter text. /
Date of sentence: / Click here to enter text. / Length of sentence: / Click here to enter text. /
Court Sentenced at: / Click here to enter text. /
Place an ‘x’ next to the type of court: / Civilian Court: / ☐ /
Military Court: / ☐ /
Is attendance on a Venture Trust programme a condition of court / probation order / CPO?(please mark ‘X’ in appropriate box)If yes please provide details below: / YES / ☐ /
NO / ☐ /
Click here to enter text.
Are there any outstanding charges, court causes or warrants? (please mark ‘X’ in appropriate box) If yes please provide details below: / YES / ☐ /
NO / ☐ /
Click here to enter text.
Is the candidatesubject to any restrictions of liberty; e.g. a curfew, HDO, tagging order?(please mark ‘X’ in appropriate box) If yes please provide details below: / YES / ☐ /
NO / ☐ /
Click here to enter text.
Does the candidate you are referring have convictions for any of the following? (please mark ‘X’ in appropriate box)
Sexual Offences / YES / ☐ / Recent Serious Violence / YES / ☐ /
NO / ☐ / NO / ☐ /
Fire Setting / YES / ☐ / Racially aggravated offence / YES / ☐ /
NO / ☐ / NO / ☐ /
If you answered yes to any of the above, please provide details below:
Click here to enter text.
Is the candidate subject to any legal conditions or orders that would exclude them from obtaining certain jobs or working with certain people, e.g. children?
(please mark ‘X’ in appropriate box) / YES / ☐ /
NO / ☐ /
If you answered yes above please provide details in a supplementary letter or attach a recent CJSWR with most current risk assessments
GENERAL BACKGROUND INFORMATION:
Please provide a breakdown of any other offending history (offence types, dates and court outcomes)
Click here to enter text.

CANDIDATE’S ARMED FORCES INFORMATION

SERVICE OVERVIEW Please provide as much information as possible
Armed Service:
Please place an ‘x’ in the appropriate box / British Army / ☐
☐ / Basic Training Location: / Click here to enter text. /
Royal Navy / ☐ / Basic Training Completed? Please place an ‘x’ in the appropriate box / YES / ☐ /
Royal Air Force / ☐ / NO / ☐ /
Please place an ‘x’ in the appropriate box below: / Length of Service: / Click here to enter text. /
Regular / ☐ / Reservist / ☐ / Date of Discharge: / Click here to enter text. /
Please place an ‘x’ in the appropriate box below: / Reason for Discharge: / End of Contract / ☐ /
Currently Serving / ☐ / Veteran / ☐ / Discharge of Notice / ☐ /
Service Number: / Click here to enter text. / Discharge Medical / ☐ /
Branch/Regiment: / Click here to enter text. / Discharge Service No Longer Required / ☐ /
Rank Attained: / Click here to enter text. /
POST-SERVICE SUPPORT
Has any post-service support been accessed e.g. for housing, employment, medical issues? Please mark an ‘X’ in the appropriate box / Yes / ☐ /
No / ☐ /
If yes, please provide further information: / Click here to enter text. /
Is this support still ongoing? / Click here to enter text.

Funding Partners:A full list of our current funding and delivery partners can be found on theVenture Trust website;

Page 1/8

160629_VentureTrustReferralForm