PRIVATE AND CONFIDENTIAL
PRINCE’S TRUST
THE TEAM PROGRAMME
PARENT / CARER / GUARDIAN REFERRAL FORM
This form is used to support a referral of a young person aged 16-25 to the 12-week Team and
personal development programme.
For programme start dates or more information call 01273 667788 ext 484.
Alternatively visit the Prince’s Trust Team page on City College Brighton and Hove website
http://www.ccb.ac.uk/public/courses/princes-trust
SECTION 1 - PERSONAL DETAILS OF THE YOUNG PERSON
Family name:
Forenames:
Date of birth: (dd/mm/yyyy)
Age:
Male 
Female 
Telephone number(s)
Young person’s address:
Postcode:
TEAM programme being referred to:
Brighton & Hove  Shoreham  Bognor 
SECTION 2 – YOUR DETAILS
Please provide the details of the person completing this form
Name:
Address
Relationship to Learner:
Contact Numbers:
Postcode:
Contact email:
PRIVATE AND CONFIDENTIAL
SECTION 3 – PORTRAIT OF THE YOUNG PERSON
A – WHY DO YOU THINK THE TEAM PROGRAMME WOULD BE
SUITABLE FOR THE YOUNG PERSON?
This information will enable to Team Leader to effectively support the individual during the Team
programme.
Please do not try to give a character reference but rather the most useful information i.e.
 How would we know when the young person was having a bad day?
 How could we best support them when they are struggling?
 What does the young person like/dislike? Is there anything that they are passionate about?
 Are there any particular situations that may cause the young person to feel stressed or
anxious?
If there is information you wish to share but do not feel it appropriate to record on this form, please
feel free to contact the Team Leader directly.
SECTION 4 - DOES THE YOUNG PERSON FACE CHALLENGES WITH
ANY OF THE FOLLOWING: (tick all that apply)
Basic skills
Self-confidence
Self harm and/or
attempted suicide
Anger management
Health problem /
allergy
Disability or
learning need
Alcohol issues
Drug issues
Working in a team

Mental health
issues
Problems in
relationships
Other (please
specify)





PRIVATE AND CONFIDENTIAL
SECTION 5 - PLEASE GIVE FURTHER DETAILS ON ANY OF THE
ANSWERS IN THIS FORM, OR ANY OTHER SIGNIFICANT FACTORS
THE TEAM LEADER SHOULD BE MADE AWARE OF:
Please feel free to use separate sheets of paper to continue if required.
SECTION 6 - OFFENDING BACKGROUND
Tick if not applicable
If the young person is an offender please give the following details:
Details of last offence (and any unspent conviction):
Was the offence/ unspent conviction:
V
Date of last conviction:
Length of sentence:
Number of prison sentences
Is there a risk of the young person re-offending?
Yes
No
If yes, please rate level of risk :
Low
Medium
Has the young person been in trouble with the police (ie never been convicted but has been
getting in trouble and starting to enter the criminal justice sector?)
SECTION 7 - CUSTODY DETAILS
YOI or prison name:
Prisoner number:
Earliest date of release:
Contact address on release
Is the young person on a Tagging Order, or will they be on release:
Is the young person on Home Detention Curfew, or will they be on release
PRIVATE AND CONFIDENTIAL
SECTION 8 - FAMILY SITUATION AND SOCIAL SERVICES
What is the young person’s housing or family situation?
Please give details of any social services involvement with the young person?
Is this young person classified as a ‘child in need’ or has a child protection plan or Common
Assessment Framework (CAF) in place?
SECTION 9 - MENTAL HEALTH NEEDS
Please give details if the young person has any mental health needs:
SECTION 10 - DISABILITIES
Please give details if the young person has a disability:
SECTION 11 - LEARNING NEEDS
Please give details of any statement of educational need/special needs/learning difficulties etc
and/or problems with reading, writing or maths
ALCOHOL/DRUG CONCERNS
Does the young person have any issues/addictions with the below?
Drugs
Please give details:
Alcohol
Please give details:
PRIVATE AND CONFIDENTIAL
SECTION 13 - ANY OTHER ISSUES
Is there anything else you think we should know? (e.g. membership of gang, anger management
issues, victim of bullying, bereavement, debt issues etc)
For all referrals, arrangements will be made for the appropriate Team Leader to see the
details on this form. An informal meeting will be set up between the young person and the
Team Leader prior to the start of the programme.
SECTION 14 - DECLARATION
I understand that the information that I am providing is being collected under the Data Protection
Act 1998. It will form part of the young person’s file and if the young person requests to see
information that The Prince’s Trust Group holds on them, under the Act, we would release this
information.
Signed:
Date:
If returning by post please send to
City College Brighton and Hove,
Princes Trust Team, Pelham
Street,
Brighton, BN14FA