Provision Referral Form

Name of person submitting the form *

What is your relationship to the child or young person? *

Email of the person submitting the form *

Phone number of the person submitting the form *

Child/Young person's name *

Child's name

Child/Young person's date of birth *

Address of the child/young person *

Parent/guardian's name if different from above

Parent/guardian name

What is their relationship to the child? *

Parent/guardian's email address (if different from above and you have permission to share it)

Parent/guardian email

Parent/guardian's contact number (if different from above and you have permission to share it) (copy)

Parent/guardian contact

Does the child/young person have an EHCP?

How does the young person communicate and how can we best support them with this?

Please summarise the main areas of need and include any formal diagnosis

Please summarise the child/young person's main interests and strengths

What is the main aim of the alternative provision/service you are seeking? Please link to relevant EHCP Section F outcomes, if appropriate. *

We offer active learning and outdoor well-being support. Which service(s) are you interested in? *

1:1 well-being support at home/garden

1:1 active learning at home/garden for those who are ready for academic learning

2:1 outdoor based provision at an agreed site

Small group sessions

School based outreach and inclusion support - those at risk of permanent exclusion

Distance Learning Boxes - interest based continuous learning provision

Family EOTAS coordination support

Other

How many sessions/hours are you looking for a week? (Our sessions vary from 1 to 4 hours and are reviewed on an individual basis of needs

When would you ideally like the provision to start? Do you have a preference on days of the week you would ideally like the provision?

Is the child/young person currently on roll in a school or have previously been on roll in a school? If yes, please name and date the period of attendance below.

Does the child/young person access any other alternative provision? Please list below.

Are there any professionals currently supporting the child/young person as part of a multi-disciplinary team? Please list below.

Do the parents/guardians consent for us to contact them regarding an initial visit to their home?

Yes

No

Please upload any relevant documents or reports

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Provision Referral Form

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