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)
10. Participant declaration(Required)