Teencamps-UK Intervention Assessment Form
Information that we require
** Important - Please give as much detailed information as possible in your answers as this will be used to assess if your young person will be suitable to attend **
Information and Optional Services
Which type of intervention are you applying for? Please only tick the actual services you require
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Male One to One Residential in the UK - 7 day minimum
Consultation
Dates required?
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Male One to One Residential in the UK. Minimum 7 day stay but no limit on the length of stay. Please advise in the "FULL Details" section which dates you require from and to and in which country.
Consultation @ £1200.00 per 60 min session. Please advise suitable times and dates you require.
Young Persons Details
Full Name of Young Person
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First Name
Middle Name
Last Name
Gender
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Male
Female
Age
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Date of Birth
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FULL details of issues and family history. Give as much information as possible.
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WHAT does the family hope this intervention will achieve?
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How would you describe your parenting style?
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Are you open to changing your parenting style if necessary?
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Has the young person had Counselling/ and or any Interventions previously? If Yes then please give FULL details of the type of Counselling received, how long, who with etc.
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Are they on any medication? If Yes then please provide details including prescription details, amount to be taken, how often, side effects experienced, etc.
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Do they have any current or previous mental health issues or have they ever been hospitalised? If Yes then please provide FULL details including dates, how long for, location etc
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Have they ever self harmed? If Yes then please give FULL details.
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Do they use drugs or alcohol? If Yes then please give FULL details of what they take, how much, how often etc.
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Do they have any previous criminal convictions or have they been involved in any recent criminal activity and have any court cases pending? If Yes then please give FULL details
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Do they have a disability? If Yes then please give FULL details
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Are they in education? If Yes then please give FULL details including school address. If not, then please advise what current education they are receiving
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Are they involved with any external Services (including Social Services)? If Yes then please give FULL details
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Do they have any allergies and are these life threatening? If Yes then please give details
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Do they have any special dietary requirements? If Yes then please give details
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Does the young person speak fluent English?
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Yes
No
Where did you hear about Teencamps-UK?
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Parents / Guardian Details
Parent / Guardian FULL NAME
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First Name
Middle Name
Last Name
FULL address and postcode
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Telephone Number
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Email Address
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Payment Method
I agree to pay in GBP (£) by
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BACS
Terms and Conditions
I have read, understood & agree to Teencamps-UK Terms & Conditions.
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Yes
I agree that I will collect my young person from the residential if they are dismissed for any reason or if I chose to remove them. See T&C's on the website at www.teencamps-uk.com
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Yes
Submit
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