Services — MOTION POTENTIAL

REFERRERAL FORM

This form may be completed by parents, carers, schools, education providers, or local councils. If you are completing this form on behalf of a parent or carer, you must ensure you have obtained their permission beforehand. Please read through the entire form carefully before completing it and ensure you have all the necessary information available.

Who is completing this referral form?

Parent/carer

School / education provider / council

Other

1. REFERRER INFORMATION

If you are the parent or carer, please leave this section blank.

Referrer name

First Name

Last Name

Referrer Role

Organisation

Referrer Email

Referrer Telephone Number

(###)

###

####

2. PARENT / CARER INFORMATION

This section must be completed, regardless of who is making the referral.

Parent/Carer Name/s

Parent/Carer Email

Home Address

Emergency Contact Number

(###)

###

####

3. THE CHILD

Child's Name

First Name

Last Name

Preferred Name/Nickname

Please indicate the name or nickname the child prefers to be called. This helps us address them in a way that feels comfortable and familiar.

Child's Date of Birth

Allergies

Medical Conditions

Including diagnoses, disabilities

Triggers

Please note any triggers that may cause the child distress or anxiety (e.g., loud noises, certain topics, changes in routine).

Does The Child Have an EHCP?

Type 'YES' or provide further details.

4. EXERCISE

Exercise Safety

Please indicate if the child has any medical conditions that could be exacerbated by exercise, along with any specific advice previously given regarding physical activity.

Current Activity Status

Please describe the child's current activity levels over the past three months, including daily non-exercise activities, sports, or club participation.

Exercise Disclaimer

Please type your full name below to confirm your acknowledgment and acceptance of the following terms: 1. I understand that all physical activity carries inherent risks of injury. 2. To the best of my knowledge, there are no medical or other reasons why the child named on this form cannot safely participate in a physical activity programme. 3. I acknowledge that Motion Potential will not be held liable for any injury or damage resulting from the activities provided, except in cases of negligence or breach of duty by Motion Potential. 4. If I am not the parent or legal guardian of the child, I confirm that I have obtained permission to complete this section on their behalf.

5. FUNDING

Is Funding in Place for This Service?

A separate service level agreement will need to be completed before programmes can commence.

Yes

Pending

Self-Funding

6. SCHEDULE

Start Date

Leave blank if not known

YYYY

End Date

Leave blank if not known.

YYYY

Number of Hours Required Per Week

1 hour per week minimum, term time only, aligned with Swindon Borough Council's term time schedule.

Programme of Interest

Leave blank if not known.

Engage + Evolve

Building Blocks

Teenage Lifts

7. REPORTING

Main Contact for School/Provider

This is who we will contact with updates surrounding attendance, progress and for general enquiries. If the child is not enrolled with a school or education provider please leave blank and updates will be sent directly to parent / carer.

First Name

Last Name

Contact Role

Contact Email

Contact Telephone Number

(###)

###

####

Absence Reporting Email

Absence Reporting Telephone Number

(###)

###

####

8. NEEDS ASSESSMENT

General Wellbeing

How would you describe the child's mood or temperament most of the time? (Calm, anxious, easily frustrated, etc.)

Academic/Developmental Needs

Please outline these below.

Social/Emotional Needs

Please outline these below.

Physical/Sensory Needs

Please outline these below.

Behavioural Needs

Please outline these below.

Communication Needs

Please outline these below.

Interests and Strengths

Please outline these below.

Additional Information

Is there anything else you feel is important for us to know about the child’s needs or circumstances?

9.RISK ASSESSMENT

Aggressive Behaviour

Likely

Unlikely

Tendency to Abscond or Run Away

Likely

Unlikely

Harm to Others

Likely

Unlikely

Self-Harm

Likely

Unlikely

10. INFORMATION SHARING

Consent

I consent to the sharing of the information provided in this form with relevant professionals involved in the care and education of the child. This information will be handled in accordance with Motion Potential's Data Protection Policy."

Yes

11. CONFIRMATION

Parental Consent

Please type your full name to confirm that you are the parent of the child named on this referral or, if you are not the parent or carer of the child, you have obtained full permission to complete and submit this form on their behalf.

REFERRALS

Thank you!