This form is to be used by professionals seeking to refer a young person to the Full Circle Education

Training Programme. We offer a structured three day a week provision with alternative accreditation
opportunities. A funding commitment MUST be agreed between the referring agency and Full Circle
Education, and this will be discussed once the referral has been agreed in principle.
See our website www.fullcircleeducation.com for more information about our programme.

Referring Agency Details

Date of Referral: _______/_______/_______

Name of Referring Agency: _________________________________________

Address: _________________________________________
_________________________________________
_________________________________________

Name of Referring Contact: _________________________________________

Position Within Organisation: _________________________________________

Telephone Number/s: Work:____________________________________

Mobile:___________________________________
E-mail Address: _________________________________________

Young Person Details

Name of Young Person: _________________________________________

Gender: Male ( ) Female ( )

Name of Parent / Guardian: _________________________________________

Address: _________________________________________
_________________________________________
_________________________________________

Home Telephone Number: _________________________________________

Mobile Telephone Number: _________________________________________

Date of Birth: ———/———/———- Age:_______________

Academic Year Group: Year 10 ( ) Year 11 ( )

Is the young person eligible

for free school dinners? Yes ( ) No ( )
Referral Information (1)

Why are you referring this young person to ‘Full Circle Education’?
Please tick all that apply in each section, and provide ALL additional and relevant informa-
tion either:
A. In the box provided below each section OR
B. As attached documents from the young person’s file

School Factors

1. At Risk of Temporary/ Permanent Exclusion ( )

2. Has already been temporarily excluded (Please provide details) ( )
3. Persistent disruptive behaviour in the classroom ( )
4. Failure to follow instructions ( )
5. Rudeness and abuse towards staff and others ( )
6. Not entered for GCSE’s ( )
7. Moderate Learning Difficulties ( )
8. Low Level Literacy/Numeric ( )
9. Statemented ( )
10. Non-attendance to school ( )
11. School Phobic ( )
12. Regular Truancy ( )
13. Other Reasons:_____________________________________________ ( )

Please expand and give any additional and relevant information about the young person
here:

Social/ Family/ External Factors

1. Known or suspected involvement in anti-social behaviour ( )
2. Has been arrested (please provide details) ( )
3. Substance abuse (alcohol, drugs etc.) ( )
4. Friends, siblings or family in trouble with the police ( )
5. History of violence/ abuse in the family ( )
6. Problems at home ( )
7. Problems with health (mental, emotional, physical) ( )
8. Young Person is on the Child Protection Register ( )
9. Other ______________________________________________________ ( )

Please expand and give any additional and relevant information about the young person
here:
Referral Information (2)

How long and in what capacity have you known this young person?

Is the young person being referred currently on any other alternative

programmes or schemes?

Full Circle Education only offers a three-day a week training programme

on Monday, Wednesdays and Fridays. What educational provision will be
made for the young person on the Tuesdays and Thursdays?

School : Negotiated Timetable ( )

Home Study ( )
Alternative Training ( )
Work Experience ( )
Other ( )

Will the young person being referred be entered for any qualifications
(e.g. GCSE, GNVQ, BTEC)?

Yes ( ) No ( )

If Yes, please indicate below those which he/she will be entered for:

Please enter any other relevant information about the young person in-
cluding their:
A. Strengths & Achievements
B. Skills
C. Specialist Interests
D. Additional Needs & Specific Requirements
Referral Information (3)

Ethnic Group (A) White

1. White British
(including white English, Scottish or Welsh or mix of these) ( )
2. White Irish ( )
3. Any Other White Background
Please State________________________________________ ( )

Ethnic Group (B) Mixed

1. White and Asian ( )
2. White and Black African ( )
3. White and Black Caribbean ( )
4. Any other Black Background
Please State _________________________________________ ( )

Ethnic Group (C) Asian or Asian British

1. Bangladeshi ( )
2. Indian ( )
3. Pakistani ( )
4. Any other Asian Background
Please State _________________________________________ ( )

Ethnic Group (D) Black or Black British

1. Black African ( )
2. Black Caribbean ( )
3. Any other Black Background
Please State _________________________________________ ( )

Ethnic Group (E) Chinese and Vietnamese

1. Chinese ( )
2. Vietnamese ( )

Ethnic Group (F) Other

Please State:________________________________________________ ( )

Please Return the completed form to:

Damon Moore—Project Manager

Full Circle Education
The Samuel Montagu Centre
126 Broadwalk
Kidbrooke
London
SE3 8ND
Tel/Fax: 0208 8562050 Mobile: 07834 156482
E-mail : fullcircle.ed@btinternet.com