WESTMINSTER REFERRAL FORM

Please read this important guidance on referring a child to Chance UK.
STEP 1 – PROFESSIONAL UNDERSTANDING
Please click here to find out more about the Chance UK service; or call us on 020 7281 5858 if you need any more information. Before you refer, please also check the criteria below:
Referred children must….
  • Be 5 to 10 years old at point of referral: children in Y6 cannot be referred
  • Be at primary school and/or resident in Westminster
  • Have consent for the referral to Chance UK from the child’s main carer (see box below)
  • Score 14 or more on the Main Carer SDQ behavioural questionnaire (see page 3)
(Click here for multi-lingual versions of SDQ)
  • Also score 16 or more on the School SDQ behavioural questionnaire (see page 4)
Referred children should not….
  • have asevere learning difficulty that would prevent them from having the necessary level of comprehension, communication and self-reflection skills to engage fully with our programme
  • have a diagnosis of autism
  • have previously received the Chance UK service
STEP 2 –PARENTAL CONSENT AND SDQ
Obtain consent from the parent/carer of the child for this referral and confirm this in the box below; they will also need to complete theMain Carer SDQ on page 3.This document will help referrers explain the Chance UK mentoring service to children and families: Who we are, what we do.
Have you obtained consent from the main carer for this child to be referred? / YES / NO
STEP 3 – ADD INFORMATION
Complete the referral form, which is in 4 sections:
1)Basic Information
2)Assessment Questions
3)School Behavioural Assessment - Goodman Strengths and Difficulties Questionnaire (SDQ)
4)Main Carer Behavioural Assessment - Goodman Strengths and Difficulties Questionnaire (SDQ)
Please note, we may need to ask additional or clarifying questions about this child to decide if Chance UK is a suitable service for them at this time.
STEP 4 – SUBMIT
  • Password protect or encrypt this referral form
  • nd CC in any other professionals involved
  • Send the password for this referral in a separate email to

OFFICE USE ONLY / REFERRAL RECEIVED / REFERRAL ALLOCATED / ?
SCHOOL (16+) / ES / CP / HA / PP / TOTAL / PS
MAIN CARER (14+) / ES / CP / HA / PP / TOTAL / PS
  1. BASIC INFORMATION

Date the Referral Form was completed / 120000012/01/16
CHILD / First name(s) of child
Surname of child
Other names used for the child
Gender / M or F(delete as appropriate)
Date of Birth
Current age
School year / Y1 Y2 Y3 Y4 Y5(delete as appropriate)
Ethnicity
Faith
FAMILY / Main carer(s) name(s)
Main carer(s) relationship(s) to the child
Home Address
Postcode
Phone numbers
Alternative contact method (e.g. email)
What language is spoken at home?
Is an interpreter required? / NO / YES – which language?
Is this a single parent household? / NO / YES
Who else is directly involved in caring for the child, and what is their relationship to the child?
SCHOOL / Referrer’s name
Referrer’s role at School
Name of School
Address / Postcode
Email
Phone
OTHER PROFESSIONALS INVOLVED WITH CHILD OR FAMILY
(e.g. Social Worker, Therapist, Family Support Worker) / Name / Name
Role / Role
Organisation / Organisation
Address and Postcode / Address and Postcode
Email / Email
Phone / Phone
Name / Name
Role / Role
Organisation / Organisation
Address and Postcode / Address and Postcode
Email / Email
Phone / Phone
  1. ASSESSMENT QUESTIONS

Please outline your reasons for referring this child to Chance UK.
It is essential that you describe the child’s behaviour.
YES / NO / DON’T KNOW
Has an Early Help Assessment (or equivalent) been completed for this child or family?
Has there ever been any safeguarding concerns or actions regarding this child or family? If yes, please outline in the box below:
....
The child is currently subject to, or classified as:
Please provide details in the box below: / (delete as appropriate)
Social Care Assessment, Child In Need Plan, Child Protection Plan, Looked After Child, Fostering, Family Support Worker
….
Have Social Care been involved in the past?
If yes, please outline the involvement in the box below:
....
Does the child have any special educational needs?
Does the child have either a Statement of Needs or an Education Health Care Plan? / PLEASE ATTACH
Does the child have Attention Deficit Hyperactivity Disorder?
Does the child have an Autistic Spectrum diagnosis?
Does the child have any learning difficulty that would prevent them from having the necessary level of comprehension, communication and self-reflectionskills to engage fully with ourprogramme?
If yes, please outline this in the box below:
….
Do you receive Pupil Premium funding for this child?
Has the child been excluded from school in the last year?
If yes, when was this and for how long? / WHEN?
HOWLONG?
Does the child receive free school meals?
Do any members of the child’s family have a criminal history?
Are our mentors or staff at risk of danger or abuse from family members,their associates, or animals at the home?
If yes, please outline any risks in the box below:
....
3. SCHOOL BEHAVIOURAL ASSESSMENT
ONLY to be completed by a member of School staff that knows this child well
Name of school staff member completing this SDQ
Role at School
Date SDQ completed
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
True / Somewhat True / Certainly True / Office use only
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
SCHOOL / ES / CP / HA / PP / TOTAL / PS

Thank you for referring to Chance UK, and for your continued support.

4.MAIN CARER BEHAVIOURAL ASSESSMENT
ONLY to be completed by the child’s Main Carer
Multi-lingual versions of the SDQ can be found here:
Name of Main Carer completing this SDQ
Relationship to the child
Date SDQ completed
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
True / Somewhat True / Certainly True / Office use only
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
MAIN CARER / ES / CP / HA / PP / TOTAL / PS

Thank you very much for completing these questions!