IslingtonReferral Form
Child’s Details / Child’s race / ethnicityFirst name / Please mark X in relevant box
Surname / White
Age / Date of birth / School year / British
Gender / Male / Female / Irish
Language spoken at home / Religion / Other (specify):
Home address / Black or Black British
Caribbean
African
Other (specify):
Telephone (home) / Mobile / Mixed
Is this a single parent household? / Yes / No / White and Caribbean
Please identify the child’s main carer(s): / White and Black African
Name / Relationship to child / White and Asian
Name / Relationship to child / Other (specify):
Who else is involved in the child’s upbringing, e.g. child’s father, mother’s partner? / Asian or Asian British
Indian
Pakistani
Is an interpreter required? / Yes / No / Bangladeshi
If yes, please specify which language / Chinese
Other Ethnicity
Have you told the child’s parent / carer about this programme?
Is the parent/carer aware of the ECHO project – an evaluation of Chance UK’s
service – and how they would be involved if the referral is eligible? (A parent
information leaflet is provided) / Specify:
Please outline your reasons for making this referral and give any other relevant information.
Use additional sheets or submit a separate attachment if necessary.
Referrer’s details / For office use only
Name / Position / Date referral received
Agency
Address / Meets criteria Yes / No
Result of risk assessment
Phone / E-mail / High Low Inconclusive
Name and address
of child’s school if
different from above / Score PS
Date referrer informed of
assessment result
Name of child’s class teacher if different from above
Name of social worker / Date allocated to staff member
Telephone*
Child / family background
Is the child or family known to social care? If yes, please give details:
Child protection plan / Fostering / Children in need
Looked after children / Family support worker / Drugs and alcohol
Other
Is the child or family known to Educational Welfare? / Yes / No / Don’t know
Does the Child/Family Consultation Service know the child / family? / Yes / No / Don’t know
Is the child or family known to the probation service? / Yes / No / Don’t know
Are our mentors / staff at risk of danger or abuse from family members or their associates? If yes please give details. / Yes / No / Don’t know
Home life
Do any members of the child’s family have a criminal history? / Yes / No / Don’t know
Do any members of the child’s family have a problem with addiction? / Yes / No / Don’t know
Do any of the child’s friends have a negative influence on him / her? / Yes / No / Don’t know
How consistent is the parent / carer’s supervision of the child?
Very poor / Poor / Below average / Average / Good / Very good / Don’t know
How stable is the child’s background / family situation?
Very poor / Poor / Below average / Average / Good / Very good / Don’t know
Please rate the child’s relationship with his or her mother
Very poor / Poor / Below average / Average / Good / Very good / Don’t know
Please rate the child’s relationship with his or her father
Very poor / Poor / Below average / Average / Good / Very good / Don’t know
School life
Does the child have attention deficit / hyperactivity disorder? / Yes / No / Don’t know
Has the child been diagnosed with autism? / Yes / No / Don’t know
Does the child have a severe learning difficulty that would prevent him/her from having the necessary level of understanding to engage with the programme? / Yes / No / Don’t know
Is there a CAF in place for this child? / Yes / No / Don’t know
Has the child been excluded from school? / Yes / No / Don’t know
For how many days was the child excluded in the last school year?
Does the child have special education needs? If yes, please give details / Yes / No / Don’t know
Does the child have a statement of needs? / Yes / No / Don’t know
Does the child receive free school meals due to low family income? / Yes / No / Don’t know
Please rate the parent/carer’s relationship with the school
Very poor / Poor / Below average / Average / Good / Very good / Don’t know
Please rate the child’s academic record
Very poor / Poor / Below average / Average / Good / Very good / Don’t know
Please rate the child’s school attendance record
Very poor / Poor / Below average / Average / Good / Very good / Don’t know
Please state the reasons for any frequent or prolonged absences from school
Truancy / Illness / Don’t know / Other (please specify below)
ECHO Project – an evaluation of Chance UK’s early intervention mentoring programme
Chance UK’s service is being evaluated to find out more about its impact on children’s lives. The Social Research Unit at Dartington will run the evaluation in a project called ECHO: Evidence for Children’s Outcomes.
School staff will be asked to assist in the evaluation by giving their valuable perspective on a child’s behaviour via a short questionnaire. Please read carefully the enclosed information sheet about the ECHO project, and then sign the statement below if you agree to take part.
I have read the information sheet about the evaluation of Chance UK’s service and I understand that:
- The information I provide will be used by the research team to contact the child’s family in order to assess their suitability for Chance UK’s service.
- I will be asked to complete the Strengths and Difficulties Questionnaire (SDQ) and this will be used to assess the child’s eligibility for the service and to monitor changes in the child’s behaviour and emotional wellbeing.
- If the child is involved in the evaluation, the research team will contact me to arrange a time for me or another member of school staff to complete the SDQ at two follow-up time points (around nine and sixteen months after referral) so that the research team can monitor changes in the child’s outcomes.
- Completion of the questionnaires is voluntary and I can stop taking part in the project at any time.
- The information I provide will be kept confidential and stored appropriately.
- The information I provide will be analysed and reported at a group level where no individual or their views could be identified.
- The research project will be reviewed by an independent ethics committee.
Knowing the above, I agree to take part in this project / Yes / No
Signed:
Date:
Goodman Strengths and Difficulties Questionnaire (SDQ)
Copyright Robert Goodman 1997. Permission granted for use.
Please rate the child’s behaviour over the last six months, or over the last school year, by marking X in one box in each row below.
Not Somewhat Certainly
true true true / Office
Considerate of other people’s feelings
Restless, overactive, cannot stay still for long
Often complains of headaches, stomach-aches or sickness
Shares readily with other children (treats, toys, pencils etc)
Often has temper tantrums or hot tempers
Rather solitary, tends to play alone
Generally obedient, usually does what adults request
Many worries, often seems worried
Helpful if someone is hurt, upset or feeling ill
Constantly fidgeting or squirming
Has at least one good friend
Often fights with other children or bullies them
Often unhappy, down-hearted or tearful
Generally liked by other children
Easily distracted, concentration wanders
Nervous or clingy in new situations, easily loses confidence
Kind to younger children
Often lies and cheats
Picked on or bullied by other children
Often volunteers to help others (parents, teachers, other children)
Thinks things out before acting
Steals from home, school or elsewhere
Gets on better with adults than with other children
Many fears, easily scared
Sees tasks through to the end, good attention span
Name of person who completed this SDQ
Position
Child’s name
Date
For office use only
For office use onlyPlease circle your response
PP ( ) A (5–10) B (4) N (0–3)
ES ( ) A (6–10) B (5) N (0–4)
CP ( ) A (4–10) B (3) N (0–2)
HA ( ) A (7–10) B (6) N (0–5)
Total ( ) A (16–40) B (12–15) N (0–11)
PS ( ) A (0–4) B (5) N (6–10)
Scored by / Date
Meets criteria Yes / No
Monitoring information entered on database by
Follow up information taken and attached here by
Notes
Please return your completed referral form to:
Chance UK
Senior Programme Manager – Hackney and Islington
020 7281 5858 ext. 208
Charity Registration No.1046947 – Company Registration No.3057840