Tick all eligibility criteria that apply to the young person Please provide additional details in – the Case Summary Demonstrated Criteria Non Behavioural – (Please select as appropriate) Young person is living with a parent or care giver ☐ At risk of entry to care due to anti-social, challenging or offending ☐ behavior High affiliation with anti-social peers ☐ At least one episode of short term care in the last 12 months ☐ Multiple referrals to a of agencies to support in tackling behaviour ☐ Demonstrated Criteria Behavioural – (Please select as appropriate) Aggressive behaviour (violence, fighting, property destruction) ☐ Violence within the home directed at parents or siblings ☐ Permanent exclusion or dropped out of education ☐ Multiple fixed period exclusions for problem behavior ☐ Unauthorised absence from school ☐ Recent criminal behaviour (or suspected) ☐ Problematic and escalating substance misuse impacting behaviour and ☐ / or family Running away ☐ Other high risk behaviours including gang affiliation, drug selling, knife crime, weapons and firearms ☐ Please provide details
Tick all eligibility criteria that apply to the young person – Please provide additional details in the Case Summary Criteria – Non Behavioural Demonstrated (Please select as appropriate) Young person is living with a parent or care giver ☐ At risk of entry to care due to anti-social, challenging or offending behavior ☐ High affiliation with anti-social peers ☐ At least one episode of short term care in the last 12 months ☐ Multiple referrals to a of agencies to support in tackling behaviour ☐ Criteria – Behavioural Demonstrated (Please select as appropriate) Aggressive behaviour (violence, fighting, property destruction) ☐ Violence within the home directed at parents or siblings ☐ Permanent exclusion or dropped out of education ☐ Multiple fixed period exclusions for problem behavior ☐ Unauthorised absence from school ☐ Recent criminal behaviour (or suspected) ☐ Problematic and escalating substance misuse impacting behaviour and / or family ☐ Running away ☐ Other high risk behaviours including gang affiliation, drug selling, knife crime, weapons and firearms Please provide details ☐
MIXED%20FOUNDATION%20REFERRAL%20FORM.docx