This document is also available in Braille and large type. Please let us know if you require
help with translation
Referral form for Targeted Short Breaks
To be completed by child/young person with their family or carers
Completed forms can be sent directly to your Targeted Short Break
service of choice. Details of what is available can be found by going to
the Leeds Local Offer website:
(http://www.leeds.gov.uk/residents/Pages/Short-break-offer.aspx).
Or alternatively forms can be sent to
placementserviceshortbreaks@leeds.gov.uk, Placement Service, Kernel House,
Killingbeck Drive, Leeds, LS14 6UF, tel: 0113 3783659, who can help you decide
the most appropriate service.
If you would like information, advice and support to access inclusive
mainstream services, please contact Scope in Leeds (tel: 0113 272 7531 or 0800
085 1879).
Section 1
Your name:
Who else lives in your home?
Do they have any needs or
access any services?
Your home address:
Home Phone number :
Mobile Phone number:
Email Address:
Parental Responsibility held by
Your date
of birth:
Your School/Nursery:
Date form
completed:
Your Lead
Professional
and their
contact details:
Your Social worker:
and their
contact details:
Emergency contact:
If anyone has helped
you complete this
form, please list here:
Preferred language:
G Drive/Family Placement/All Forms/Children’s Scheme Forms/Short Breaks Forms for CYPSC
Section 2. All about you
(Please describe yourself, for example what you like/dislike, activities you get
involved in, what you are good at, what you are interested in, your hobbies, any
dietary needs, cultural/religious needs, what makes you feel anxious or upset)
(Please include a picture of yourself if you would like to)
Section 3.
Please tell us a little bit more about yourself to help us understand more about you.
Please tick one of the following categories, which best describes you:
Your Ethnicity
Code
Please
Tick
Your Ethnicity
Code
White British
WBRI
Pakistani
APKN
White Irish
WIRI
Bangladeshi
ABAN
Traveller of Irish Heritage
WIRT
Any other Asian background
AOTH
Any other White backgound
WOTH
Caribbean
BCRB
Gypsy/Roma
WROM
African
BAFR
White and Black Caribbean
MWBC
Any other Black background
BOTH
White and Black African
MWBA
Chinese
CHNE
White and Asian
MWAS
Any other ethnic group
OOTH
Any other Mixed background
MOTH
If other ethnic group please
state which
Indian
AIND
Refused
REFU
Information not yet obtained
NOBT
2
Please
Tick
Section 4.
How would you describe your disability?
Section 5
Do you have a Statement / Education, Health and Care Plan (EHCP)?
Do you have an Early Help Assessment (also known as a CAF)?
Medical information:
Do you have any medical needs, such as
medication you take, epilepsy including patterns
of seizures or other health related conditions?
If yes, please explain what they are:
Do you have any allergies that a setting
may need to know about?
If yes, please explain what they are:
Section 7.
Communication needs:
How do you communicate? Verbal? Non verbal? BSL, Makaton?
Does you use signs or symbols (for example, board maker, Picture Exchange
Communication)?
If you communicate non-verbally, is body language, eye pointing, or other forms of
communication significant? How do you communicate with the person who looks after you,
and at school?
3
Section 8
Day to day needs
Are you able
to get around
the house and
elsewhere by
yourself?
Not at all
With help
Without help
Is there anything else you want to tell us?:
Are you able
to feed
yourself?
With help
Without help
Is there anything else you want to tell us?:
Are you able to
With help
wash / dress
yourself?
Is there anything else you want to tell us?:
Without help
Are you able to
With help
use the toilet
by yourself?
Is there anything else you want to tell us?:
Without help
4
What time do you - Go to bed?
Bedtime
Wake up?
What do you like to
do before you go
to sleep?
Is there anything else you want to tell us?:
Do you have any needs in relation to your Hearing?
Please tell us about this:
Do you have any needs in relation to your Speech?
Please tell us about this:
Do you have any needs in relation to your Sight?
Please tell us about this:
5
Do you need any attention through
the night?
Yes
No
Section 9
Behaviour and skills
Please tell us about your skills and achievements:
Do you enjoy being with other children and adults? If you have any difficulties please
tell us.
Do you have friends or family you like to be with?
How are things at school, nursery or college?
Tell us about any worries, fears or obsessions that you may have
Are you very active or find it
hard to sit still?
Comment:
Yes
Occasionally
No
Do you need/like lots of
attention from others?
Comment:
Yes
Occasionally
No
6
Do you sometimes wander off
or make a run for it?
Comment:
Yes
Occasionally
No
Do you ever injure yourself or
others?
Comment:
Yes
Occasionally
No
How can we help you to manage any of the issues from sections 7, 8 and 9?
Comment:
Would you or your family like to tell us anything else, which may assist us?
7
Are you accessing any short breaks now?
If yes, please tell us about them:
What have you tried and has it worked for you and your family?
What types of short break are you interesting in accessing?
What difference will this make to you and your family?
Yes
No
Which times/days would be preferred for short breaks?
Daycare
Full weeks
Weekdays
Weekends
am pm Yes
Yes
Yes
am
pm
No
No
Other/comments:
8
No
For office use.
Disability Type
Code
Yes/No
Disability Type
Code
Specific learning difficulty
SPLD
Visual impairment
VI
Moderate learning difficulty
MLD
Multi-sensory impairment
MSI
Severe learning difficulty
Profound & multiple learning
difficulty
SLD
Physical disability
PD
PMLD
Autistic spectrum disorder
ASD
SEMH
Other difficulty / disability
SEN support but no specialist
assessment of type of need
OTH
Social, emotional and mental
health
Speech, language and
communication needs
Hearing impairment
SLCN
NSA
HI
To be completed by designated worker and line manager:
Name and signature of designated worker
completing essential information
Date
Job title and organisation of designated
Worker
Contact details of designated worker
Name and signature of line manager
Date
Job title and organisation of line manager
Contact details of line manager
9
Yes/No
Application for Leeds Weekend Care Association – Music Mondays
Held at: South Leeds Youth Hub, Middleton Road, Leeds, LS10 3JA
Fees are £30 per six week block, payable in advance
We do not provide transport –
Are you able to get to the Music Mondays sessions and back each week?
No
Yes
Are you a wheelchair user?
No
Yes, all the time
Yes, sometimes
e.g. for long distances
Have you got any allergies?
If yes, please list here
No
Yes
Do you require our staff to administer medication?
No
If yes, your parent/carer must complete a
medication form on arrival at each session
Yes
Emergency contact details
Contact 1
Relationship to you
Name
Telephone
Mobile
Contact 2
Relationship to you
Name
Telephone
Mobile
10
MUSICAL INSTRUMENTS
Have you ever played a musical instrument?
Yes
No
Yes
No
Have you used a PC to create your own
music?
Yes
No
Are you computer literate?
Yes
No
Have you used DJ decks before?
Yes
No
Would you be interested in learning how to
DJ?
Yes
No
If so what have you played?
How long have you been playing?
SINGING
Does you enjoy singing?
GARAGE MUSIC / SONGWRITING
DJ-ING
MUSICAL INFLUENCES
Favourite bands
1
2
3
4
5
Favourite songs
1
2
3
4
5
11
Which Course are you applying for? (NB You must attend all 6 Mondays in the block)
Please tick
BLOCK ONE: age 10-14
Monday 20th April 2015
Monday 27th April
Monday 11th May
Monday 18th May
Monday 1st June
Monday 8th June
BLOCK TWO: age 15-18
Monday 15th June
Monday 22nd June
Monday 29th June
Monday 6th July
Monday 13th July
Monday 20th July
BLOCK THREE: age 10-14
Monday 7th September,
Monday 14th September,
Monday 21st September
Monday 28th September
Monday 5th October
Monday 12th October
BLOCK FOUR: age 15-18
Monday 19th October
Monday 2nd November
Monday 9th November
Monday 16th November
Monday 23rd November
Monday 30th November
BLOCK FIVE: age 10-14
Monday 7th December
Monday 14th December
Monday 11th January 2016
Monday 18th January
Monday 25th January
Monday 1st February
BLOCK SIX: age 15-18
Monday 8th February
Monday 22nd February
Monday 29th February
Monday 7th March
Monday 14th March
Monday 21st March
How did you hear about Music Mondays?
12