#IAM Girls Club #IAM Girls Club – December 2022Do you know a young female aged 13-16 who is at risk, suffers from or has in place any of the below:• At Risk of Exclusion from Mainstream Provision• On an Education, Health & Care Plan with behavioural, emotional and/or social difficulties• Child In Need Plan• Child Protection Plan• Mild SEN• Lacks Confidence/Suffers with Depression or Anxiety If yes, please complete the below referral form. Spaces are LIMITED so please await confirmation that your space has been allocated. Self-Referral Step 1 of 3 33% YOUR DETAILSYour Name Your Age Do you receive free school meals?YesNoPostcode Contact numberYour Email Reason for referral Any additional support needs i.e. childcare restrictions, health issues, dietary requirements/allergies, learning difficulties etc. SELF ESTEEM SCALEI feel that I am a person of worth, at least on an equal plane with others.* Strongly Agree Agree Disagree Strongly Disagree I feel that I have a number of good qualities.* Strongly Agree Agree Disagree Strongly Disagree All in all, I am inclined to feel that I am a failure.* Strongly Agree Agree Disagree Strongly Disagree I am able to do things as well as most other people.* Strongly Agree Agree Disagree Strongly Disagree I feel I do not have much to be proud of.* Strongly Agree Agree Disagree Strongly Disagree I take a positive attitude toward myself.* Strongly Agree Agree Disagree Strongly Disagree On the whole, I am satisfied with myself.* Strongly Agree Agree Disagree Strongly Disagree I wish I could have more respect for myself.* Strongly Agree Agree Disagree Strongly Disagree I certainly feel useless at times.* Strongly Agree Agree Disagree Strongly Disagree At times I think I am no good at all.* Strongly Agree Agree Disagree Strongly Disagree Participant consent : I agree to my contact details being stored, accessed and used by LUV CIC and it’s subcontractors. I agree I do not agree Preferred delivery method* Online Face to face Participant agreement: I agree to attend each session, at least 5 minutes before the start and contact LUV CIC if unable to attend. I also agree to fully participate in the sessions, without judgement and maintaining confidentially of the group I agree I do not agree I have read and abide to the privacy policy stated in the footer* I have read this policy Δ Refer Someone Else Step 1 of 3 33% YOUR DETAILSYour Name Your Age Do you receive free school meals?YesNoPostcode Contact numberYour Email Reason for referral Any additional support needs i.e. childcare restrictions, health issues, dietary requirements/allergies, learning difficulties etc.Would you like to be part of our Whatsapp groupYesNoThe Whats App group will be other ladies on your course SELF ESTEEM SCALEI feel that I am a person of worth, at least on an equal plane with others.* Strongly Agree Agree Disagree Strongly Disagree I feel that I have a number of good qualities.* Strongly Agree Agree Disagree Strongly Disagree All in all, I am inclined to feel that I am a failure.* Strongly Agree Agree Disagree Strongly Disagree I am able to do things as well as most other people.* Strongly Agree Agree Disagree Strongly Disagree I feel I do not have much to be proud of.* Strongly Agree Agree Disagree Strongly Disagree I take a positive attitude toward myself.* Strongly Agree Agree Disagree Strongly Disagree On the whole, I am satisfied with myself.* Strongly Agree Agree Disagree Strongly Disagree I wish I could have more respect for myself.* Strongly Agree Agree Disagree Strongly Disagree I certainly feel useless at times.* Strongly Agree Agree Disagree Strongly Disagree At times I think I am no good at all.* Strongly Agree Agree Disagree Strongly Disagree Participant consent : I agree to my contact details being stored, accessed and used by LUV CIC and it’s subcontractors. I agree I do not agree Preferred delivery method* Online Face to face Participant agreement: I agree to attend each session, at least 5 minutes before the start and contact LUV CIC if unable to attend. I also agree to fully participate in the sessions, without judgement and maintaining confidentially of the group I agree I do not agree I have read and abide to the privacy policy stated in the footer* I have read this policy Δ