Referral Form

Trauma-informed music studio for care-experienced youth (8-18 yrs). Limited to a small cohort of committed young people. Carer must attend ALL sessions.

Email: Niall@onlynotts.co.uk | 20 Fletcher Gate, Hockley, Nottingham, NG1 2FZ

Section 1: Young Person Details

Full Name *

Date of Birth *

Age *

Gender / Pronouns

Current Placement Type *

Placement Start Date

Placement Address

Tell us a bit about the young person (interests, hobbies, dreams, etc.) *

What do they hope to get out of these sessions? *

Section 2: Referrer Details

Full Name *

Role *

Organisation *

Phone Number *

Email *

Date

Contact number of key worker

Contact number for on-call management

Section 3: Music & Creativity Interest

Has the young person shown interest in music/creativity before? (rap, beatmaking, singing, instruments, etc.) *

Section 4: Practical Commitment

Will the named carer/key worker attend ALL sessions (weekly, 1.5hrs)?

Carer Name *

Carer Phone *

Will carer attend ALL sessions? *

Comments

Consistent familiar staff who may attend (name, work number, relationship)

Transport plan (can you reliably travel weekly to 20 Fletcher Gate, Hockley, NG1 2FZ?) *

Section 5: Support Information

Known triggers, risks, behaviours, sensory needs (for trauma-informed practice) *

Other professionals involved? (CAMHS / social worker / school) + contacts

Section 6: Why Only Notts?

Why do you think this young person would benefit from our music studio? What specific outcomes do you hope for? *

Declaration

By submitting this form, I confirm:

✓ Carer will attend ALL sessions
✓ Young person can commit to 6-week induction minimum
✓ We understand Only Notts has a 3-strike behaviour contract

I confirm all of the above *