Short Breaks Referral Form for Disabled Children and Young People

Referral Form

Thank you for expressing an interest in applying for the Fun Club Short Break service. The following pages are designed to ensure that we capture sufficient initial information to help us identify the most appropriate service to meet your child’s/young person’s needs. Throughout the assessment process we want to ensure that our services are the most appropriate to meet your child/young person’s individual requirements.

Imago Fun Clubs are for children and young people with a disability aged 8-17yrs (inclusive), who live in Kent, and who require a level of additional support that makes accessing mainstream/universal services unlikely. Your children/young person should be able to manage most of their personal care independently and not require constant one to one support from staff; and must not require waking night support if accessing the overnight provision.

Once we receive the referral form you will be contacted by a member of our Short Breaks Team to let you know that we have received your form. The information provided will enable us to determine whether it is appropriate to progress to the next stage of our assessment process which will be a home visit.

The home visit will be carried out by a member of our Short Breaks team to meet your child/young person and your family to identify what is important to them, as well as their hobbies and interests and their individual support needs. If we feel at this point that our Short Breaks service will not meet your child/young person’s needs then we will signpost you to alternative services available.

Following the home visit we will use all the information you have given to assess the level of need of your child/young person, and determine whether we are able to offer a Short Break service. If we feel we are unable to provide a service we will make suggestions about other services that may assist your child/young person.

Eligibility for a Short Break provision is determined by the level of need that has been assessed. Depending on the level of need assessed this will determine the type of Short Break that is appropriate for your child/young person which we will discuss together. The activity attended by your child/young person will be reviewed after 6 months to ensure that it is meeting the needs of the individual.

ALL PERSONAL DATA THAT YOU SUPPLY IS HELD IN STRICT ACCORDANCE WITH THE DATA PROTECTION ACT (1998) Imago, John Spare House, 17-19 Monson Road, Tunbridge Wells, Kent, TN1 1LS www.vawk.org.uk [email protected] 01892 530330 Short Breaks Programme is a service of Imago Community Registered charity no 1108388 Registered company no 5354482 2 Our Short Breaks services comprise of the following opportunities: Option 1 (for ages 10-17yrs inclusive)

 Residential overnight provision during school holidays  Residential overnight provision during weekends  Day activities during school holidays (this option will be open to Children and Young People aged 8-17yrs inclusive)

Our overnight provision and day activities offer disabled children and young people an opportunity to enjoy new activities, experiences and develop a wider social network, helping them to develop social and life skills and enjoy independence from their families.

Over a year there will be 10 activities, booking is on a first come basis.

It is important to note that not all children and young people feel confident about overnight breaks or being away from home for a whole day; for this reason we offer trial sessions and also youth cafes as an alternative.

Option 2 (for ages 8-17yrs inclusive)

 Youth Cafes – 2 hours per week during term time. We have youth cafes for the following ages: 8-14yrs and 14-18yrs.  Youth Cafes are designed to help develop a child/young person’s talent, skill and interest. The cafes often combine both recreational and educational factors and are created to help keep children active and interested in learning.  Youth Cafes broaden a child’s/young person’s interest. They are introduced to new subjects and activities that can be both interesting and challenging to them so when they learn new skills their self-esteem grows.

All children and young people accessing either option will be invited to our Annual Disabled Children and Young People Festival held in the October half-term break. The Festival is an opportunity for children and young people from across the County to meet and enjoy a variety of outdoor activities at Kingswood in Ashford.

During the home visit staff will discuss the differing services in more detail and will give you the opportunity to ask questions and find out more information.

ALL PERSONAL DATA THAT YOU SUPPLY IS HELD IN STRICT ACCORDANCE WITH THE DATA PROTECTION ACT (1998) Imago, John Spare House, 17-19 Monson Road, Tunbridge Wells, Kent, TN1 1LS www.vawk.org.uk [email protected] 01892 530330 Short Breaks Programme is a service of Imago Community Registered charity no 1108388 Registered company no 5354482 3 Child’s first name: Surname:

Address:

Home Telephone Number:

DOB: Age: Gender: Male / Female Person(s) with Parental Responsibility:

Are there any Child Protection orders on the young person? If so please give details:

Family construction (name all persons in household):

Full Name Date of Birth Relationship to referred

ALL PERSONAL DATA THAT YOU SUPPLY IS HELD IN STRICT ACCORDANCE WITH THE DATA PROTECTION ACT (1998) Imago, John Spare House, 17-19 Monson Road, Tunbridge Wells, Kent, TN1 1LS www.vawk.org.uk [email protected] 01892 530330 Short Breaks Programme is a service of Imago Community Registered charity no 1108388 Registered company no 5354482 4 SOCIAL WORKER INVOLVEMENT Please tick: Does your child (name) ….………………………………………… have Yes No a social worker? Is the social worker in a Disabled Children’s Team? Yes No If yes, please provide the name if known ..……………………………………………………….. (If not known, please contact DCS Commissioning Team to find out) Is ………………………………………………. in care (LAC)? Yes No OVERNIGHT BREAKS Please tick: Does ……………………………………………………. receive Yes No overnight breaks in a KCC run overnight breaks unit? SSEN OR EHC PLAN Please tick: Does ……………………………………………… have a SSEN or EHC Yes No plan? Is an application for EHC plan in progress? Yes No SCHOOL Please tick: Is he/she………………………………………… in a special school? Yes No Is he/she…………………………………… in a specialist unit in a Yes No mainstream school? Is he/she……………………………………… in a mainstream school? Yes No FREE SCHOOL MEALS Please tick: Is he/she…………………………………… in receipt of free school Yes No meals?

ALL PERSONAL DATA THAT YOU SUPPLY IS HELD IN STRICT ACCORDANCE WITH THE DATA PROTECTION ACT (1998) Imago, John Spare House, 17-19 Monson Road, Tunbridge Wells, Kent, TN1 1LS www.vawk.org.uk [email protected] 01892 530330 Short Breaks Programme is a service of Imago Community Registered charity no 1108388 Registered company no 5354482 5 DLA Please tick Is the family of ……………………………………… in receipt of DLA? Yes No Highest What rate of DLA Middle Lowest DIAGNOSIS Please tick: Is he/she………………………………………………………… awaiting Yes No diagnosis?

Please complete each appropriate box in as much detail as possible:

Support needs

Does the young person require one to one Global developmental delay care/support at all times?

Permanent or long term condition (Please Learning disability (Please indicate) indicate)

Sensory disability (Please indicate) Physical disability (Please indicate)

Diagnosis of ADHD Diagnosis of ASD

Life limiting or threatening illness (Please Hearing Impairment (Please indicate) indicate)

Visual Impairment (Please indicate) Other (Please indicate)

Complex medical needs or long term condition expected to disable the child for more than one year. (Please outline)

Epilepsy Poor Self Care skills

Communication

Verbal communication used?

Non Verbal communication used? (Please discuss communication needs)

ALL PERSONAL DATA THAT YOU SUPPLY IS HELD IN STRICT ACCORDANCE WITH THE DATA PROTECTION ACT (1998) Imago, John Spare House, 17-19 Monson Road, Tunbridge Wells, Kent, TN1 1LS www.vawk.org.uk [email protected] 01892 530330 Short Breaks Programme is a service of Imago Community Registered charity no 1108388 Registered company no 5354482 6 Sleep

Does your child sleep well for their age?

If not please explain:

Child’s social and leisure needs (please tick which most reflects the child/young person)

1. The child has a routine and participates in social activities that are available within the local community with minor support

2. The child would enjoy and benefit from participating in social and leisure activities, however this is difficult as they need additional support to access the service

3. The child is socially isolated and does not attend any provision outside of school Medical needs:

1. Does the person have any allergies? 2. Does the person carry an Epi Pen? 3. Does the person receive any course of medication? (Medication plan will need to be completed)

Are there any support needs we will need to be aware of at the referral stage?

Reasons for referral – further information:

Is anyone in the household known to Does the young person show any dangerous be aggressive or violent? behaviour?

No Yes No Yes

Any dangerous weapons in the household i.e. guns, swords, martial arts discs etc?

No Yes

ALL PERSONAL DATA THAT YOU SUPPLY IS HELD IN STRICT ACCORDANCE WITH THE DATA PROTECTION ACT (1998) Imago, John Spare House, 17-19 Monson Road, Tunbridge Wells, Kent, TN1 1LS www.vawk.org.uk [email protected] 01892 530330 Short Breaks Programme is a service of Imago Community Registered charity no 1108388 Registered company no 5354482 7 If any member of the household or visitor to the household is known to be violent or excessively aggressive, please give details of any known incident:

Are there any safety issues within the home that we need to be aware of when carrying out a home visit (e.g. Dogs, remote location etc.)?

Details of referrer (Parent/Professional’s details) Full Name: Position held/relationship to the young person: Agency: Telephone: Email: Address: Line Manager’s Name: Position Held:

Signed: (Referrer) Signed: (Person with Parental Responsibility)

Date: Will you or your agency still be working alongside the young person/family? Yes / No Please give details:

How did you hear about the service?

NOTE: Please complete in full as missing information may delay the processing of the referral. Thank you.

ALL PERSONAL DATA THAT YOU SUPPLY IS HELD IN STRICT ACCORDANCE WITH THE DATA PROTECTION ACT (1998) Imago, John Spare House, 17-19 Monson Road, Tunbridge Wells, Kent, TN1 1LS www.vawk.org.uk [email protected] 01892 530330 Short Breaks Programme is a service of Imago Community Registered charity no 1108388 Registered company no 5354482 8 YOUNG PERSON MONITORING FORM ETHNICITY

Gender Age Nationality Female / Male

Ethnic Origin The classification below is that currently recommended by the Commission for Racial Equality and is used by a wide variety of public, private and voluntary bodies. White British Irish Any other White background

Mixed White & Black Caribbean White & Black African White & Asian Any other mixed background

Asian or Asian British Indian Pakistani Bangladeshi Any other Asian background

Black or Black British Caribbean African Any other Black background

Other Ethnic Groups Chinese Any other ethnic group

ALL PERSONAL DATA THAT YOU SUPPLY IS HELD IN STRICT ACCORDANCE WITH THE DATA PROTECTION ACT (1998) Imago, John Spare House, 17-19 Monson Road, Tunbridge Wells, Kent, TN1 1LS www.vawk.org.uk [email protected] 01892 530330 Short Breaks Programme is a service of Imago Community Registered charity no 1108388 Registered company no 5354482 9