CHAMPIONS REFERRAL FORM (YOUTH) v2

Please complete for 10-17 (Adult form link in the footer below)

CHAMPIONS is an innovative personal development programme helping young people aged 10-25 with experience of or at risk of offending and antisocial behaviours as suspects.

The programme is a workstream of the Lancashire Violence Reduction Network (LVRN), covering Lancashire including Blackpool and Blackburn with Darwen. It's delivered in collaboration with nine football community club organisations across the region.

We offer mentoring support, signposting, activities in the community via the local football community trusts and support into activities provided by local organisations.

We focus on understanding the young person, discovering what their aspirations are and helping them achieve them underpinned by a therapeutic behaviour change programme.

CHAMPIONS is voluntary and challenging, requiring positive commitment on the part of the client, their mentor and others involved in their support network. Please complete the form as fully as possible to enable a full assessment of the programme's suitability for the young person.

Unfortunately we're unable to support individuals with a history involving harmful sexual behaviours as a suspect.

Sections marked * are required

Estimated Completion Time: 10/15 Minutes

 

Referral Information

Identity

Client Information

Young Person Address Details

Young Person Contact Details

Parent/Guardian Details (Under 18's)

Emergency/Alternative Contact

Consent

Does the young person want to be considered for the CHAMPIONS Programme?

Does the young person consent to sharing of their information with us and contact from a Champions team member?

Does the young person consent to us making enquiries on their behalf which may include sharing and requesting personal information relating to them from LVRN partners in order to assess the programme's suitability for them and enable us to support them effectively?
Do you consent to your child being considered for participation in the CHAMPIONS Programme?

Do you consent to us making enquiries on their behalf which may include sharing and requesting personal information relating to them from LVRN partners and statutory agencies in order to assess the programme's suitability for them and enable us to support them effectively?

Consent can be withdrawn at any time by emailing info@teamchampions.co.uk quoting the clients full name & date of birth and Remove Consent in the Subject box. 

Alternatively write to:

CHAMPIONS, Lancashire Violence Reduction Network, County Hall, Fishergate, Preston, PR1 8XB.

Quoting the client's full name, date of birth and the remove consent request.

We retain client records for 6 years following programme completion/disengagment, for auditing, evaluation and safeguarding purposes.

CHAMPIONS Adult Referral Form

www.teamchampions.co.uk