Referral Form
Please complete the following details and submit
Client Personal Details
*
APEX Unit Referral to
--None--
Please select a unit
APEX - Alloa
APEX - Ayrshire
APEX - Borders
APEX - Dumfries
APEX - Edinburgh
APEX - Fife
APEX - Glasgow
APEX - Grampian
APEX - Head Office Admin
APEX - Highland
APEX - Lanarkshire
APEX - Renfrewshire
APEX - School Services
APEX - Stranraer
APEX - Tayside
*
Firstname
Ethnicity - Main Classification
--None--
White
Asian, Asian Scottish or Asian British
African, Caribbean or Black
Mixed or Multiple Ethnic Groups
Other Ethnic Group
*
Lastname
Ethnicity - Sub Classification
--None--
*
RSO/Schedule 1 Client
--None--
No
Yes
Don't Know
Other Ethnicity
Title
--None--
Mr
Mrs
Ms
*
Gender
--None--
Female
Male
Prefer not to say
Date of birth
Marital status
--None--
Married
Single
National Insurance No
Client Contact Details
Street
Preferred contact mode
--None--
Phone
Email
Text
Letter
Next of Kin
--None--
Parent
Partner
Other
Area/Town
Home Telephone
City/County
Mobile Telephone
Postcode
Email
Client Background
Accessed Apex before
--None--
Yes
No
Employment Status
--None--
Employed
Unemployed
Self Employed
Other
Details
If other(please specify)
Do you have any special needs
Have you ever served in the Armed Forces
--None--
Yes
No
If yes what was your Tag No
Other (Give details)
User consent to referral obtained
--None--
Yes
No
information given to Apex Scotland
If a school pupil what year
--None--
S1
S2
S3
S4
S5
S6
Issues/Special Notes
Reason for referral
Notes/specific group or 1-2-1 work
Incident leading to referral
Known barriers to engagement
Language
Learning difficulties
Addiction Issues
Criminal Record
Numeracy / Literacy
Homelessness
Family Caring Responsibilities
Mental Health
Attendance issues
Behaviour issues
Looked after young person
**** New List of 23 criteria below ****
From Rural Areas
From Employment Deprived Areas
Registered Long-Term Unemployed
No Work Experience
Low Skills (ISCED Level 2)
Living in a Jobless Household
Jobless Household - Dependent Children
Single Adult Home - Dependent Children
Mental Health Issues
Long-term Physical Illness/Condition
Homeless or Housing Exclusion
Above 54 years of age
Looked after a Young Person
Substance Related Condition
Armed Forces Veteran
Criminal Convictions
Migrants
Asylum Seeker
Refugee
Language
Learning difficulties
Addiction Issues
Criminal Record
Numeracy / Literacy
Homelessness
Family Caring Responsibilities
Mental Health
Attendance issues
Behaviour issues
Looked after young person
**** New List of 23 criteria below ****
From Rural Areas
From Employment Deprived Areas
Registered Long-Term Unemployed
No Work Experience
Low Skills (ISCED Level 2)
Living in a Jobless Household
Jobless Household - Dependent Children
Single Adult Home - Dependent Children
Mental Health Issues
Long-term Physical Illness/Condition
Homeless or Housing Exclusion
Above 54 years of age
Looked after a Young Person
Substance Related Condition
Armed Forces Veteran
Criminal Convictions
Migrants
Asylum Seeker
Refugee
History of violence or sexual offending
Special Instructions
Referrer Details
Date of referral
Date referral recieved
Name of referrer
Company/Organisation
Company telephone number
Company email address
Company Address
Background Information Request (For RSO and Schedule 1 Cases ONLY)
Apex Scotland promotes a “best and safest” practice approach which is underpinned by its policy and guidelines of service delivery.
Apex Scotland is committed to working in partnership with Social Work, Police and other agencies that provide services for Sex Offenders and Schedule 1 Offenders.
In order for Apex Scotland to provide a specialist employability secondary support service which complements the statutory agencies work with these types of offenders, we require the following information on the client you are referring.
Please provide information. On receiving this information we will be able to carry out a Risk Assessment prior to working with the client.
Thank you for your co-operation.
Offence Frequency
Offence History
Known Victim / Gender Group
Victim Age
Relationship to Victim
Offending Programmes Attended or About To Be Attended
Client’s Attitude to Intervention/Challenges
Current Order
Any Licence Conditions
Is Client on Sex Offender Register and/or Excluded From Working With Children List
--None--
Yes
No
Outcome of Any Risk Assessment / Any Special Interviewing Arrangements in Place
Other Areas of Possible Employment Restrictions, For example IT Access, Geographical Travel, Children’s Hearing Restrictions
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