Accessibility

1-2-1 / RRR Programme Active Sefton

The aim of the 1-2-1 programme is to help young people aged between 11 – 19 use Physical Activity to support them managing low level mental health needs. The aim of the Restart, Reset, Rethink programme is to help adults affected by Domestic Abuse, manage mental and emotional well-being through Physical Activity.

1. Participant's Full Name(Required)
What school does the person attend
Address(Required)
Emergency Contact Name(Required)
2. Details of person referring:(Required)
If referring for Participant as a relative or from other agencies such as Early Help. Please complete 3a. choose preferred centres and availability for the Participant, then go to 3c. If referring from a High School (eg. Teacher, Pastoral services, Head of SEN) go to 3b.

3. Community setting Preferred Centre
Availability (day)(Required)
Availability (Time)
4. Has the participant been affected by domestic abuse?
Physical violence, sexual abuse, controlling/coercive abuse, verbal/emotional abuse
5a. What are the participant's mental health needs ?
6. Does the participant have any Special Educational Needs and/or Disabilities (SEND) considerations or additional needs?
Eg Asthma, Diabetes, Hypermobility, etc
Eg family background, behaviour, etc.

9. Confidentiality Agreement – Person referring must discuss with the participant:(Required)

Everything discussed within this session will remain confidential between the mentor and participant.
In the event of a matter of seriousness e.g. intent to cause serious harm, disclosure of abuse/crime or abuse of someone known by the participant (list not exhaustive) the mentor will be obliged to report such disclosure to his/her manager and await direction.
Should this happen, the mentor will inform the participant immediately that their disclosure is of a serious nature and it is the mentor’s obligation to report it.

10. Participant declaration(Required)

I am happy to go ahead with the 1-2-1 Programme.

I am happy with the discussion I have had with the person referring me today.

I understand that non-attendance will mean my referral is terminated.

Please tick box to confirm the participant has read the above