Initial Referral Form

1. Young Person Details
2. Person(s) with parental responsibility / guardianship
3. Referrer details
4. Does the young person have an EHCP?
5. Details of other professionals involved in Young Person’s care (e.g CAMHS or OT)
6. Medical information (Details of any relevant medical conditions, disabilities &/or allergies)
7. Medication (Please note Overworld staff cannot administer medications without prior arrangement & consent forms completed)
Young Person’s Interests (Please advise of any particular interests, key people/pets in their life. Anything that they are interested in learning with us or any topics to avoid)
8. Sensory Profile (Details of any sensory needs, sensory aids (eg ear-defenders, fidget toys) & potential triggers)
9. Other relevant details
10. Provision requirements
Assisted Mentorship programme
Client Request
Overworld Agreed
Days
Client Request
Overworld Agreed
Transport required? (at additional cost)
Client Request
Overworld Agreed
11. Contract details & Payment details (Please provide the details of the person/organisation with responsibility for the contract & payment)
12. Transport services (Transport can be provided at an additional cost. Please provide details of your request. E.g between home & the centre & return.)
13. Photography & Videos Consent
During Overworld AMP’s day-to-day business, there are staff & young people taking photographs & videos in the center. They do this primarily to develop their mentees’ interest in creative media & for any certificated project work. We also have displays in the centre & generate social media & website promotions. As part of onboarding, you will be asked to complete a more in-depth consent form in line with our E-Safety Policy, but please indicate your overall acknowledgment & consent below:
The information contained in this document will be stored in accordance with our GDPR policy & only used by Overworld AMP staff to facilitate our administrative processes & the safe & thorough care of the young person.