Child Referral Form

Complete this form for all referrals for participants aged 16 and under to The Wild Mirror Programme and Education Partnership Programmes.

Referrer Details

Referrers Name

Role / Job Title

Organisation / School / Practice

Email

Phone

Best time to contact you

Child’s Details

Child's First name

Child's Last name

Name Known by

Date of Birth

Day

Month

Year

Address

Parent / Carer

Parent / Carer Phone Number

Parent / Carer Email

Background Information

Current school and year group

Does the child have an EHCP or identified SEND?

Yes

No

If yes, please outline needs

Do they have any Mental Health conditions that we need to be aware of?

Do we need to be aware of any agencies involved (e.g., CAMHS, Early Help, Social Care)?

Any safeguarding concerns we should be aware of?

Programme or Service

Programme you would like to apply for

Reasons for Referral

Brief Summary

Risk and Safety I understand that Wild Mane relies on referrers to provide accurate and complete information to ensure appropriate support and risk management.

I confirm that I have disclosed any information relevant to the safety or wellbeing of the participant, other group members, staff, or animals. This includes any known risk-taking behaviour, aggression, safeguarding concerns, or incidents that could affect participation or safety at Wild Mane Wilderness & Equine Therapeutic Centre.

Funding & Fees

By submitting this referral, the referring organisation confirms that it is responsible for the full cost of the programme, unless alternative funding has been agreed in writing in advance.

By submitting this form, you agree that your information may be stored in the Wild Mane system for communication and programme administration.

I agree

This information will be treated confidentially and stored in line with Wild Mane’s Safeguarding and Data Protection policies.