Venture Trust Referral Form

To refer to our Personal Development programmes please use the referral form at:

https://crm.venturetrust.org.uk/pd_referral

Thank you.

Venture Trust takes our users security and privacy concerns seriously. All data submitted via this form is encrypted from end to end by SSL. It cannot be intercepted in transmission and once submitted to our secure system it will only be viewed by authorised staff via their unique passwords.

Type of referral

Please select which of our services you wish to refer this participant to:

Personal Development: This is our core service, which includes our Living Wild, Next Steps, Inspiring Young Futures and Positive Futures programmes. Participants will join a 6-9 month programme of personal development delivered through community outreach with a key worker and a Wilderness Journey of 5-10 days.

Change Cycle: Our Change Cycle vocational course is an employability service for young people in Scotland struggling with long-term unemployment. We tackle youth unemployment by building aspiration, motivation and self-confidence while developing key employability skills.

Outdoor Therapy: This service is for those in need of counselling from qualified therapists. Participants will meet counsellors for one-to-one and group sessions outdoors in parks and green spaces. This service is currently only available to those aged 16-25 or ex-service personnel, and from one of the following local authorities: Clackmannanshire, East Lothian, Edinburgh, Falkirk, Fife, Midlothian, West Lothian.

Court Assessment Request. If you are a Court Social Worker or Clerk of Court requesting an Assessment to help decide whether someone is suitable for a Venture Trust core service as part of an order, use this option. Do not use for participants who are already subject to an Order.

scoregrid1

	Personal Development (Wilderness Journey)	Change Cycle	Outdoor Therapy	Court Assessment Request
Which type of Venture Trust service are you making a referral to? *	Which type of Venture Trust service are you making a referral to? - Personal Development (Wilderness Journey)	Which type of Venture Trust service are you making a referral to? - Change Cycle	Which type of Venture Trust service are you making a referral to? - Outdoor Therapy	Which type of Venture Trust service are you making a referral to? - Court Assessment Request

Please note: our Outdoor Therapy Service is currently only available in the following Local Authorities: Clackmannanshire, East Lothian, Edinburgh, Falkirk, Fife, Midlothian, West Lothian.

Are you referring yourself to Venture Trust? *

Court Referrals

Court/Case Reference Number

Assessment report due

Day

Month

Year

PLEASE NOTE: If the participant has convictions for any sexual offences or is on MAPPA supervision then unfortunately Venture Trust cannot accept a referral at this time.

Participant details

Has the participant worked with Venture Trust before? *

Have you worked with Venture Trust before? *

Has the participant worked with Venture Trust before? *

First Name *

Middle Name

Last Name *

Participant's Phone Number

Participant's Email

Postal Code *

Enter Postcode to lookup address

Street Address *

City *

Country

Local Authority *

Birth Date

Day

Month

Year

National Insurance No.

Gender

Gender (Other term)

Preferred pronouns

Preferred pronouns (other)

Current Issues Faced - please select all that apply:

	Yes	No
Disability	Disability - Yes	Disability - No
Homeless or Affected by Housing Exclusion (officially in the homeless 'system')	Homeless or Affected by Housing Exclusion (officially in the homeless 'system') - Yes	Homeless or Affected by Housing Exclusion (officially in the homeless 'system') - No
Care Experienced Young Person	Care Experienced Young Person - Yes	Care Experienced Young Person - No
Criminal Convictions	Criminal Convictions - Yes	Criminal Convictions - No
Current/Previous Involvement in the Criminal Justice System	Current/Previous Involvement in the Criminal Justice System - Yes	Current/Previous Involvement in the Criminal Justice System - No
Long-term Physical Illness/Condition	Long-term Physical Illness/Condition - Yes	Long-term Physical Illness/Condition - No
Mental Health Issues	Mental Health Issues - Yes	Mental Health Issues - No
Substance-related Conditions	Substance-related Conditions - Yes	Substance-related Conditions - No
History of Alcohol Abuse	History of Alcohol Abuse - Yes	History of Alcohol Abuse - No
History of Substance Abuse	History of Substance Abuse - Yes	History of Substance Abuse - No
Armed Forces Veteran	Armed Forces Veteran - Yes	Armed Forces Veteran - No
Learning Disability	Learning Disability - Yes	Learning Disability - No
Caring Responsibilities	Caring Responsibilities - Yes	Caring Responsibilities - No

PLEASE NOTE: If the participant has convictions for any sexual offences or is on MAPPA supervision then unfortunately Venture Trust cannot accept a referral at this time.

PLEASE NOTE: If you have convictions for any sexual offences or are on MAPPA supervision then unfortunately Venture Trust cannot accept a referral at this time.

Additional details (for any/all selected above)

Are there any other Issues not listed above?

Other issues (details)

Reasons for Referral

Referral date

Day

Month

Year

Referrer details

First Name *

Last Name *

Job Title

Email *

Phone Number *

Referring Organisation

Start to type your organisation name into the field below, then select the correct name from the list. If your organisation name does not appear, please click Create New and type in the full name of your organisation in the Organisation Name box below.

Organisation Name

Organisation Type

Court Referrer Sub-type

Healthcare Referrer Sub-type

Social Work Referrer Sub-type

Education Referrer Sub-type

Third Sector Partner Agencies Referrer Sub-Type

Employability Referrer Sub-type

Organisation Phone *

Out of hours or Stand by phone

Street Address

City *

Postal Code *

Additional Information

Participant's Justice Information

SCRO Number

Scoregrid 2

	Low	Medium	High
Risk To Community	Risk To Community - Low	Risk To Community - Medium	Risk To Community - High
Risk to Self	Risk to Self - Low	Risk to Self - Medium	Risk to Self - High

Please attach the risk assessment in the Documents section at the end of this form

Risk Assessment Information

Does the participant have a Shine worker?

Is the participant currently on an order?

Scoregrid 3

	Yes	No
Is participant subject to a Community Payback Order?	Is participant subject to a Community Payback Order? - Yes	Is participant subject to a Community Payback Order? - No
Is participant subject to a DTTO Order?	Is participant subject to a DTTO Order? - Yes	Is participant subject to a DTTO Order? - No
Is the participant subject to any other orders?	Is the participant subject to any other orders? - Yes	Is the participant subject to any other orders? - No

Which other orders are they subject to?

Does the Order include an Unpaid Work requirement?

How many hours of Unpaid Work are required?

How many Unpaid Work hours are remaining?

scoregrid6

	Yes	No
Is participant subject to a Structured Deferred Sentence?	Is participant subject to a Structured Deferred Sentence? - Yes	Is participant subject to a Structured Deferred Sentence? - No
Is participant subject to bail conditions?	Is participant subject to bail conditions? - Yes	Is participant subject to bail conditions? - No
Are there any outstanding charges, court causes or warrants?	Are there any outstanding charges, court causes or warrants? - Yes	Are there any outstanding charges, court causes or warrants? - No
Is the participant subject to any restrictions of liberty?	Is the participant subject to any restrictions of liberty? - Yes	Is the participant subject to any restrictions of liberty? - No
Is the participant subject to any legal orders that would exclude them from obtaining certain jobs or working with certain people?	Is the participant subject to any legal orders that would exclude them from obtaining certain jobs or working with certain people? - Yes	Is the participant subject to any legal orders that would exclude them from obtaining certain jobs or working with certain people? - No

Structured Deferred Sentence Details:

Bail Conditions Details:

Outstanding charges, court cases or warrants details

Restrictions of liberty Details:

Legal Orders that would exclude them from obtaining certain jobs or working with certain people (Notes)

Is attendance on a Venture Trust programme a condition of court order/CPO?

Type of condition

Details if on condition to attend Venture Trust

Current Offences

In this section please fill in details of the participant's current offence

Type of Offence(s)

Non-sexual crimes of violence

Sexual crimes

Crimes of dishonesty

Fire-raising/vandalism/etc.

Other crimes (drugs/offensive weapons/etc.)

Miscellaneous offences (common assault/breach of the peace/etc.)

Motor vehicle offences

Date of sentence

Day

Month

Year

Length of sentence

Court sentenced at

Details of offence

Does the participant have any review dates due soon?

Date of Review:

Day

Month

Year

Justice Information

Does the participant have previous offending history?

Type of Previous Offence(s)

Non-sexual crimes of violence

Sexual crimes

Crimes of dishonesty

Fire-raising/vandalism/etc.

Other crimes (drugs/offensive weapons/etc.)

Miscellaneous offences (common assault/breach of the peace/etc.)

Motor vehicle offences

Previous Offending History

Do any current or previous offences include the following:

Scoregrid

	Yes	No
Fire Setting	Fire Setting - Yes	Fire Setting - No
Racially Aggravated Offence	Racially Aggravated Offence - Yes	Racially Aggravated Offence - No
Recent Serious Violence	Recent Serious Violence - Yes	Recent Serious Violence - No

If yes to Fire Setting, please provide details below

If yes to Racially Aggravated Offence, please provide details below

If yes to recent serious violence, please provide details below

Any Other Information

Armed Forces Information

Armed Service

Length of service

Currently Serving or Ex-Forces

Regular or Reservist

Basic Training Location

Basic Training Completed

Service Number

Branch/Regiment

Rank Attained

Date of discharge

Day

Month

Year

Reason for discharge

Discharge of notice (further info)

Discharge medical (further info)

Discharge Service No Longer Required (further info)

Have any post-service support been accessed e.g for housing, employment, medical issues? *

Please provide further information

Is this post-service support still ongoing?

Outdoor Therapy

Previous Counselling Experience

scoregrid6

	Less than 3 months	3-6 months	6-9 months	9-12 months	A year or more
Duration of previous counselling	Duration of previous counselling - Less than 3 months	Duration of previous counselling - 3-6 months	Duration of previous counselling - 6-9 months	Duration of previous counselling - 9-12 months	Duration of previous counselling - A year or more

scoregrid7

	In the last year	1-2 years ago	2-5 years ago	More than 5 years ago
Time since previous counselling	Time since previous counselling - In the last year	Time since previous counselling - 1-2 years ago	Time since previous counselling - 2-5 years ago	Time since previous counselling - More than 5 years ago

Who was the previous counselling with?

Do you have somewhere where you live that you can have a private conversation?

	Yes	No
Private space	Private space - Yes	Private space - No
Private space (out of home)	Private space (out of home) - Yes	Private space (out of home) - No

What are the main reasons you think counselling would be helpful for you/your participant right now? *

Please give as much detail as possible as this will help us in our initial assessment process. Please include information around the issues that have brought you to counselling and how they impact on you in your day-to-day life. This may include some information around your mental and physical health, your social and family situation, important life events etc. This could also be helpful to include something about what you hope to gain from outdoor therapy.

Preference for male or female counsellor *

Consent to work with trainee *

All qualified counsellors are required to do placements as part of their training. Trainee counsellors are in the second or third year of their training and have been assessed as “fit to practice”. This means that their theoretical understanding and counselling skills have been assessed as suitable to take on clients in a trainee counsellor role. They are fully supervised and registered with a governing body.

I do not wish to work with a trainee counsellor

I would be willing to work with a trainee counsellor

If you have any relevant documents to upload, you can do so here. Click on each section to expand then select the document type and add any details in the relevant fields. Then use select file to choose your document and hit Upload.

Document Upload

Document 1

Document Date

Day

Month

Year

Document Type

Document details

Author

Document

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.

Document 2

Document Date 2

Day

Month

Year

Document Type 2

Document details 2

Author 2

Document 2

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.

Document 3

Document Date 3

Day

Month

Year

Document Type 3

Document details 3

Author 3

Document 3

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Math question * 1 + 4 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.