Life Track Online Request Form

Child/ Young Person's Information

Part 2 of 3
Child/ Young Person's initials*
Child/ YP Date of Birth*
DD/MM/YYYY
Age of Child/ Young person*
Gender*
School Year*
Ex- Year 8
Name of Child/ YP's primary care giver/ parent
Primary care giver/ parent's contact details
Dietary/ Allergy information
Medical information
Additional needs
Referral history
Any other comments which may be of interest
Ex- Behavioural/ emotional traits. Child/ young persons interests and dislikes

Programme Preferences

Part 3 of 3
Length of programme required

12 weeksOther
Additional weekly sessions required

YesNo
If answered 'Yes' to the above, please state how many extra session/ week you would like
Preferred day(s) of the week

MondayTuesdayWednesdayThursdayFriday
Proposed start date

MonthDayYear
Date
Life Track- Nurture programme

PROCESS

1. Online request form completed by school
2. Initial meeting between NFS and school/ Observation of child or young person/ Individual risk assessment completed ( no charge)
3. Decision made by NFS & by the school that the programme is suitable for the child/ young person
4. Nurture contract signed between school and NFS (Includes start date, subsequent dates and formative meetings) and consent forms filled in and signed.
5. Programme commences (Tracking report after every session by NFS)
6. Formative meetings between all parties (method of communication agreed)
7. Summary assessment – reintegration plan/ continuation of programme.
Should be Empty:

School's Details