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Young persons details
Details of the person being referredEvaluation code
(VT office use only)Candidate
NameDate of birthCandidate
Address
Postcode
(Postcode is essential for monitoring purposes)GenderMaleFemaleMobile phone noOther phone numberDate referred Young persons next of KinName
Address
Relationship Telephone number(s)Notes
Details of Lead ReferrerDate of
referral Referrers office address
Postcode
Referrers
nameReferrers
job titleReferrers email addressName of referrers organisationReferrers Phone No
Referrers Fax No Key workers details (if applicable)Name and job title
Address:
Phone no: Other contacts details (if applicable)Name and job title
Address:
Phone no:
Young persons situation
To be completed by referrer - General Background InformationPlease describe the young persons current social circumstancesPlease describe support networks available / general health / accommodation statusDomestic or other issues relevant to course attendanceAreas of personal development to work onEmployment, education and trainingCurrently unemployed?YesNoUnknownSigned on at Job Centre?YesNoUnknownIf applicable, how long has the candidate been signing on?
How long since the candidate completed education, training or left a job?
Highest current qualification:
Young persons ethnicityWhite - ScottishAsian or Asian British Chinese White - EnglishAsian or Asian British IndianWhite - WelshAsian or Asian British PakistaniWhite - IrishAsian or Asian British BangladeshiBlack or Black British - CaribbeanAsian or Asian British Other Black or Black British - AfricanGypsy/TravellerBlack or Black British - OtherMixed BackgroundOther ethnic background (please state)
Young persons fitness levelHighAverageLowUnknown
Please place an X in all that apply to the candidateHomelessEconomically inactive (workless)Ethnic minorityLone parentLack of work experienceNEET aged 16-19History of substance abuseRegistered unemployedAsylum seekerHistory of alcohol abuseCriminal recordEmployedLiteracy or numeracy problemsPreviously offended (please give details on Justice page)At risk of becoming NEET on leaving schoolDisabled (excl health, numeracy, literacy or learning)No qualificationsLong term unemployedMental health issuesEU migrant workerSeasonal workerPhysical illnessNon-EU migrant workerPart time workerFamily/caring responsibilitiesSelf employedRefugee Leaving (or currently in) careWorking voluntarilyIn need of education, employment or trainingApplied for/enrolled in the military (e.g. army, navy, RAF)Young persons medical information
Please place an X in all that apply to the young person. You must provide further details below if any apply, including dosage and frequency of drugs/alcohol/medication use.AsthmaPrescribed medication past monthAddiction past or presentEpilepsyPhysical or other disabilityHepatitis C / HIV testedDiabetesPregnantAlcohol useTuberculosisSpecial dietary requirementsDrug useAny other medical conditionFood intake problemsResponsible for childrenAttended hospital in last 2 yearsMental health illnessFears / phobiasAllergy(s)Self harmMethadonePrescribed medication - currentNeeds support with reading, writing or numeracy
Further details on any of the above (continue on a separate sheet if necessary)
Young persons justice information
Main detailsSCRO number (if applicable)
Is the young person you are referring subject to a care or criminal justice order?
If yes please complete further sections below.YesNoMain (index) offenceType of offenceDate of sentenceCourt sentenced atCJA (Scotland only)Is VT attendance conditional?YesNoIs the young person subject to legal conditions that may prevent them from working in certain jobs or with certain people?YesNoAre there any outstanding charges, court cases or warrants?YesNoIf you answered yes to any of the above, please provide details in a supplementary letter or report.
CPO Disposal Information (if applicable)DetailsStart dateEnd dateHours givenHours completedUnpaid workSupport/
counsellingOther (specify)
Offending historyDoes the individual you are referring have convictions for any of the following?Sexual offencesYesRecent serious violenceYesNoNoFire settingYesRacially aggravated offenceYesNoNoIf you answered yes to any of the above, please provide details in a supplementary letter or report with a current risk assessment if available.
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