WBC VS ASB Referral Form | Havant Borough Council

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Declaration

Please note all data and information submitted within this form will be shared between Waterlooville Boxing Club and Havant Borough Council for monitoring and evaluation purposes. By completing and submitting this document, you consent to the information being shared between the two organisations regarding all delivery aspects of the ‘WBC vs ASB project’.

Havant Borough Council’s privacy statement

(https://www.havant.gov.uk/service-privacy-notices)

Name of Child/ Young Person:

Date of birth:

Age:

Gender:

Parent details

Parent / Guardian Name:

Parent / Guardian Contact number:

Relationship to young person

Address:

Address

City/Town

ZIP/Postal Code

Does the young person have a disability?:

If yes please give details:

School details

School contact name:

School contact details:

Social work details:

Social Worker name (if applicable):

Social Worker contact number (if applicable):

Social Worker email (if applicable):

Please note that any child under MAPPA or who has committed sexual offences will not be accepted on the programme as this is beyond our Threshold. Is the child or young person involved with MAPPA or have they committed a sexual offence?

Please give details of offence below:

Please detail any other agencies involved eg: ELCAS / family support:

Risk Level Details

Level of Vulnerability if known:

High

Medium

Low

Re/offending Risk:

High

Medium

Low

Risk of Serious Harm:

High

Medium

Low

Is there a risk to . . .

Self

Staff

Others

Please select the project outcomes that you feel may be appropriate for the child / young person:

Anger management

Weapon awareness

Problem solving skills

Social skills

Relationship building / Restorative activities

Resilience

Coping with peer pressure

Coping with bullying

Impact of bullying on others

Consequences of behaviour

Identity

Understanding the impact of Hate /Prejudice

Online Safety

Substance awareness

Other (please specify)

Referral Agency Information

Referral Organisation:

Referring Staff Name:

Phone Number:

Email:

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This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

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