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.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nunc quis lorem sed justo aliquam maximus at ac lectus. Phasellus feugiat dictum tellus a consequat. Vivamus ultricies elementum auctor. Quisque ac molestie elit. Praesent quis pulvinar diam. Donec lorem tortor, vulputate et erat eu, convallis sodales est. Maecenas a urna sagittis, pretium urna ac, dignissim ligula. Morbi nec nibh ac ante interdum vulputate quis sed est. Vivamus nec sagittis nulla.

Donec aliquet vulputate hendrerit. Curabitur mattis, tellus quis iaculis consectetur, massa quam accumsan nibh, sit amet vestibulum ligula eros ut orci. Sed gravida accumsan quam, ac viverra lacus venenatis id. Phasellus laoreet id ante vitae luctus. Praesent sed leo lectus. Integer vel eros auctor, vestibulum mauris et, sollicitudin ligula. Praesent faucibus dictum purus, at vestibulum nibh sollicitudin ullamcorper. Mauris nibh est, placerat non odio eget, imperdiet tempus est. Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Aenean facilisis nibh at urna efficitur faucibus. Praesent lacinia erat ipsum, a pharetra tellus rhoncus ut. Suspendisse sollicitudin vel ligula ac egestas. Ut porttitor a enim id condimentum. In dolor nulla, consequat sit amet finibus vitae, fermentum sed sem.

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

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nunc quis lorem sed justo aliquam maximus at ac lectus. Phasellus feugiat dictum tellus a consequat. Vivamus ultricies elementum auctor. Quisque ac molestie elit. Praesent quis pulvinar diam. Donec lorem tortor, vulputate et erat eu, convallis sodales est. Maecenas a urna sagittis, pretium urna ac, dignissim ligula. Morbi nec nibh ac ante interdum vulputate quis sed est. Vivamus nec sagittis nulla.

Donec aliquet vulputate hendrerit. Curabitur mattis, tellus quis iaculis consectetur, massa quam accumsan nibh, sit amet vestibulum ligula eros ut orci. Sed gravida accumsan quam, ac viverra lacus venenatis id. Phasellus laoreet id ante vitae luctus. Praesent sed leo lectus. Integer vel eros auctor, vestibulum mauris et, sollicitudin ligula. Praesent faucibus dictum purus, at vestibulum nibh sollicitudin ullamcorper. Mauris nibh est, placerat non odio eget, imperdiet tempus est. Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Aenean facilisis nibh at urna efficitur faucibus. Praesent lacinia erat ipsum, a pharetra tellus rhoncus ut. Suspendisse sollicitudin vel ligula ac egestas. Ut porttitor a enim id condimentum. In dolor nulla, consequat sit amet finibus vitae, fermentum sed sem.

10. Participant declaration(Required)