Referring For Early Intervention Support at The ClementJames Centre

Thank you for taking the time to fill out this referral form. If you need support filling out this form, please contact reception@clementjames.org or give us a call on 020 7221 8810.

If you would like to discuss the case further before making a referral, please email earlyintervention@clementjames.org or give us a call on 020 7221 8810.

Please note:

The Early Intervention Support service is available to children and young people in Year 1 to Year 11, who either live in or attend a school in Kensington and Chelsea or Westminster.

We do not provide Early Intervention Support at an independent review panel stage.

This service is in high-demand and referrals will be prioritised based on level of need. You will usually get a response within one week from submitting your referral.

Privacy Notice

At The ClementJames Centre, we're committed to protecting and respecting your privacy.

Please see our privacy notice attached here, and tick here when both you and the young person's parent/guardian have read and agree to the terms laid out in it.

Who We Can Support

If the young person does not fit our criteria but you would like our help to find an organisation who can support them, please contact earlyintervention@clementjames.org or give us a call on 020 7221 8810.

Please select the borough the young person is a resident of, housed in or attends a school in:

We also have criteria that clients need to meet to access support. At least one of the following means that the young person is able to access support at the Centre.

Please select any of the following that apply to the young person:

Family receiving benefits

Family have a household income of less than £25,000

Living in social housing (this includes council, temporary accommodation and housing associations)

Receiving free school meals

Your Details

It is helpful for us to have your details, should we need to contact you about this referral.

Full Name

Organisation

Other:

Role

Email

Contact Number

How will you still be working with the young person being referred to us going forward?

Can we contact you about this referral? We will only do so to discuss details relating to the referral, when such details are needed in order to best support the young person.

Please tick here if you would like to be subscribed to our mailing list to hear about upcoming workshops, programmes, events and opportunities at The ClementJames Centre.

Young Person's Educational Information

The following information will allow us to offer appropriate support to the young person being referred. Please give as much information as possible as this information will be used to prioritise referrals.

Is the young person at risk of exclusion or have they already been excluded?

The young person is at risk of exclusion with an accumulation of behaviour points

The young person is at a high risk of exclusion having received final warnings and the prospect of suspension is being discussed

The young person has been excluded

Please provide details of the young person's Early Intervention needs, including as much information as possible in relation to their exclusion:

Please provide details of the young person's Early Intervention needs, including as much information as possible in relation to them being at risk of exclusion:

Please provide details of the young person's Early Intervention needs, including as much information as possible in relation to them being at a high risk of exclusion:

Young Person's Educational Information Continued

Which year group is the young person in?

What school does the young person attend? (Only complete if the child is currently attending Primary School.)

What school does the young person attend? (Only complete if the child is currently attending Secondary School.)

Does the young person have a diagnosis or are they awaiting a diagnosis for SEN (Special Educational Needs)?

Awaiting SEN diagnosisSEN diagnosis

Please can you provide us with more details:

Does the young person have or are they awaiting an EHCP (an education, health and care plan)?

Awaiting EHCPEHCP in place

Please can you provide us with more details:

Is the young person in a mainstream school?

Please can you provide us with more details:

Does the young person have experience with the Youth Justice System?

Please can you provide us with more details:

Young Person's Details

Please only give us the following details with the parent/guardian's explicit consent and after they have read and agreed to our privacy notice.

First Name

Last Name

Date of Birth

Gender

Self-described gender, if known:

Ethnicity

Self-described ethnicity, if known:

Post Code

Guardian Contact Details

Parent/Guardian Contact Number

Parent/Guardian Email

Please provide details of the young person's emergency contact:

Emergency Contact Full Name

Emergency Contact Telephone Number

Accessibility Needs

Does the young person have any physical accessibility needs that we should know about?

Please provide us with more details

Please tick here if the young person will need assistance to exit the building in the event of an emergency evacuation. Staff will prepare a Personal Emergency Evacuation Plan (PEEP) for the young person.

Professional Involvement

Are there any other professionals involved in the young person's case that you are aware of? (Please select all that apply):

Other:

Contact Details

If they consent to their contact details being shared with us, please provide details for the primary professional the young person is working with below (unless this is yourself):

Full Name

Role

Email

Contact Number

Submit Your Form

Please submit the form below.