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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 and delivered in collaboration with nine football community club organisations across the region.

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

We provide client mentoring, support clients into activities in the community via the local football community trusts and support into other local services and organisations which can improve their wellbeing.

Participation in CHAMPIONS is voluntary and challenging, requiring positive commitment on the part of the client, their mentor and others involved in their support network.

Unfortunately we're currently unable to support young people with a history of harmful sexual behaviours as suspects.

Sections marked * are required

Estimated Completion Time: 10 minutes.

Referral Information

Referral Source

Date of Referral

Referring Organisation (if applicable)

Name of Person Making Referral

Job Title (if applicable)

Phone Number

Email Address

Reason for Referral (background of person and offending/antisocial behaviours)

Known Offences (convictions or where a suspect)

Ever Been Admitted to Hospital for a Knife or Assault Injury?

Factors Relevant to The Individual (Select Which Apply)

Is the Young Person Currently Accessing Other Services?

Other Services (Further Information)

Known risk factors we should be aware of

Identity

Forename

Preferred Name/Nickname

Middle Name

Surname

Maiden Name (if applicable)

Preferred Pronoun

Date of Birth

Gender

Nationality

Ethnicity*

Religion

Client Information

Employment Status

Any Disabilities/Health Conditions?

If yes, please select all that apply

GP/Name of Surgery (if known)

GP Phone Number (if known)

Current Address

Address 1

Address 2

Town

Post Code

Residential Status

Young Person Contact Details

Contact Phone

Any Contact Preferences/Instructions

Emergency/Alternative Contact

Contact Notes

Benefit Status

Are You Currently in Receipt of Benefits?

Consent

Young Person Referral Consent

CHAMPIONS ADULT REFERRAL FORM (link to under 18's form can be found in footer below)