Inclusion projects referral form

Referral form

Please fill in the form below which will be sent to our Participation team. Alternatively you can contact us directly at participation@lyric.co.uk

Young Person's Details

Please tell us the Young person's name

Age

DOB (required)

Contact address (required)

Postcode (required)

Telephone

Mobile (required)

Email address (required)

Details of Referral Agency

Please provide the name of the referral agency

Name and Position of referrer

Referral contact address

Referral telephone

Referral email

Please provide details of Lead Professional if different to referrer

Please provide details if this young person has a Social Worker

Eligibility

Is the Young Person any of the following, please tick as many boxes as applies.

NEETAt risk of becoming NEETSocially excluded/ at risk of exclusionSENDisabledAn Offender/Ex-OffenderRefugee or Asylum Seeker (with indefinite leave to remain)

Which West London borough does the young person currently live? (please tick)

Reasons for Referral to Lyric Hammersmith
Please provide a summary of the young person’s current situation and their eligibility, and their long term goals. Please include whether they are working with other support agencies

Young person’s comments on referral, Please include what you hope to achieve on the project and details of the art forms of interest.

Summary of Young Person's Details
Education and employment & highest-level academic achievement to date. Please include details of any English and Maths Qualifications.

Social and behavioural development

Family and environmental factors

Personal health

Any other information that will help us to support this young person

I refer this young person to the Lyrc Hammersmith Arts Training
Name of Referrer

Date

I confirm that the above information is correct to the best of my knowledge and that I am authorised to submit it (required)