Love4Life: Core Referral Form

Referrer ID

Referrer Link

TRUE

Empowering young people aged 11-18 to build confidence and make positive choices in their health and relationships.

Love4Life specialises in supporting vulnerable girls* in Leicestershire, Leicester & Derby to develop their self-esteem and form positive and empowering relationships by offering Love4Life groups, one-to-ones and workshops at school and in the community.
We deliver targeted relationship and sex education to support young people facing difficulties in these areas and provide honest and age-appropriate resources to help them understand their sexual health, how to stay safe and the potential risk of sexual exploitation.
All of our work embeds positive self-worth, body image and the handling of emotions in order to help a young person become more resilient. Our belief is that once young people feel good about themselves they are more likely to make positive choices in their health and relationships.
For more information on whether a young person is suitable for our support visit Our Young People (love4life.charity)
For details of the types of support we offer go to Our Love4Life Services (love4life.charity)

For any questions contact your local Love4Life coordinator:

Fawn.Kitson@love4life.charity - Derby

Laila.Harrison@love4life.charity - Loughborough

Alisha.Roberts@love4life.charity – Leicester

*Currently Love4Life works with those who identify as girls, or who experience the particular challenges associated with being born female or presenting as female. If you’d like to discuss further whether our service is right for a particular young person then please get in touch.

Section A - Young Person’s details

In which area does the young person live?

First Name

Last Name

Address

Town/City

Postcode

Date of Birth

DD/MM/YYYY

Gender

Please Specify

Full Name of School/College

School/College Postcode

Please enter a postcode with a single space, e.g. LE1 1AJ

Year Group

If this young person has been excluded, please provide the year group that they would currently be in if still at school/college

Does the young person have a disability or learning need?

YesNo

Please give details:

Does the young person have any medical conditions or allergies?

YesNo

Please give details (i.e. asthma, allergies, dyslexia):

The following information helps us to better understand our service users and ensure we are providing a diverse and inclusive service. If you or the young person are not comfortable sharing this information you can leave it blank.

Ethnicity

Other - please specify:

Religion

Other - please specify:

Sexuality

Other - please specify:

Is the young person currently eligible to receive free school meals?

Section B - Parent/Guardian details

(If you are over-16 and self-referring please provide your contact details here as well)

Primary Parent/Guardian Details

First Name of Parent / Guardian

Last Name of Parent / Guardian

Parent/Guardian Address:

Parent/Guardian Postcode:

Parent/Guardian Telephone

Parent/Guardian Email

Relationship to Young Person

Secondary Parent/Guardian Details (optional)

First Name of Parent / Guardian

Last Name of Parent / Guardian

Parent/Guardian Address:

Parent/Guardian Postcode:

Parent/Guardian Telephone

Parent/Guardian Email

Relationship to Young Person

What are the young person’s current living arrangements?
e.g. with parents, in care, temporary housing

Section C - Referrer's Details

Are you the young person's parent/guardian?

YesNo

Is this a self-referral?

YesNoI.e. are you referring yourself to Love4Life? PLEASE NOTE that you must be at least 16-years-old to refer yourself

Referrer's Details

First Name

Last Name

Position Held

This could be your job title or your specific role

Organisation

Organisation Name

Relation to Young Person

Telephone

Email

Would you be happy to receive newsletters and other marketing communications from Love4Life?

Other Professionals Involved

Are any other professionals currently supporting the young person who is being referred?

YesNo

First Name

Last Name

Position held:

Email

Telephone

Agency Name

Notes

Please provide any details or context you feel are relevant

To add details of another professional, click the 'Add another response' link below

It is important to ensure that both the young person and their parent/guardian are aware that a referral is being made and have consented to their information being shared.

	Yes	No
Please confirm if the young person is aware that a referral has been made?
Please confirm if their parent/guardian is aware that a referral has been made?

If consent has not been sought, please let us know why:

Reasons for Referral

	Please tick all boxes that apply
Involved in concerning sexual behaviour
Engaging in sexting or other unsafe online activity
In an unhealthy or unsafe relationship
May be at risk of child sexual exploitation
Requires relationships information, advice and guidance
Struggles with body image
Has worryingly low self-esteem / self-worth
Struggles to form and maintain successful relationships (inc. friendships, family)
Lacks self-confidence / May experience social anxiety
Has experienced peer-pressure or bullying
Is involved in negative friendship groups
Feels isolated or without support
Poor emotional wellbeing*
Other

Other referral reasons:

Please provide as much additional information as you can to support these statements:

It is particularly useful for us to know about other support networks the young person does/doesn’t have; the situation at home and at school; and any specific incidents that have led to concerns.

	Yes	No
Has this young person been excluded or are they are at risk of exclusion?
Is this young person persistently absent from education?
Does the young person have an EHCP (Education, Health & Care Plan)?
Is this Young Person subject to a Child Protection Plan/Child In Need Plan?
Is this young person a looked after child?

*Please note we are not a specialist mental health charity. Where a young person’s needs are exclusively or predominantly linked to their mental health, or they are experiencing crisis symptoms (e.g. suicidal thoughts, severe self-harm), they will be better with specialist support.

We are always happy to work alongside mental health professionals to provide more informal support, such as Love4Life groups, to address issues like self-esteem, body image and social anxiety where appropriate.

If in doubt, please get in touch with us to discuss it further.

We may get in touch with you, or other professionals whose details have been provided here, to discuss this referral in more detail before accepting the young person onto our programme.

In line with GDPR, we will also need to confirm written consent from the parent/guardian for the referral and will speak to the young person to check they wish to proceed with our support. At this point the young person will be provided with a Privacy Notice, which they will need to agree to in order to access our services.

If for any reason it is not appropriate to gain parental consent, please contact us.

Please enter your initials to confirm your referral: