Appendix A: Request for individual tuition from theIndividual Pupil Support Service

All requests for tuition as alternative provision to what is ordinarily available at school will be placed on the IPSS Referral and Allocation Panel (RAP)

Please return this form to the Individual Pupil Support Service by email:

Type of request (Please highlight your referral)
Medical / Exclusion / SEND
Pupil Information
Pupil’s name / Male/Female
Date of birth / Year group
School / UPN:
Ethnicity
Home address / Local authority
Name of parents or carers / Mother:
Contact number:
Email address:
Home address:
(if different from above) / Father:
Contact number:
Email Address:
Home address:
(if different from above)
Other professional involvement
Early Help and Assessment Planning Tool completed / Yes/no
Lead professional:
Report attached: Yes/No
Child looked after by the authority / Yes/no
Lead professional:
Child protection plan/child in need plan / Yes/No
Lead professional:
Report attached:
CAMHS / Yes/no
Clinician details:
Report attached: Yes/No
Other services
and named professional / Educational psychology:
Education Welfare Service:
Social Care Team:
Health:
Youth Offending Team:
Other:

Educational Information

Key Stage / Assessed Curriculum Level
Key Stage 1
Key Stage 2
Key Stage 3
Maths
English
Science
ICT
MFL
Humanities
Key Stage 4
GCSE options / Expected Levels

Medical request information

Name and position of medical professional
Address of medical professional
Please explain the medical condition behind the request for this child
For how long do you anticipate tuition will be needed
For CAMHS/FACT referrals please enclose the care plan.
Has an individual health care plan been arranged: yes/no
If yes please attach:
If no has a meeting been arranged at school to agree an IHCP
Please include any other information that could help us plan and work more effectively with the child concerned to provide a continuum of care.
Signed:
Position:
Date:

Please note that medical referrals will not be considered unless accompanied by a signed letter from the consultant concerned with this child. A signed, official letter containing all the above information sent from the relevant consultant replaces the need for this page to be completed.

Exclusion information
When exclusion details have arrived from the lead exclusions and reintegration officer the lead tutor should forward this request to the home school
Date of Permanent Exclusion
Details of any fixed term exclusions
Fair Access Panel date where pupil will be considered
Special educational needs and disability request information
Education, health and care plan
coordinator
Date of SEN Panel where request was agreed
Please give a brief explanation for the request
Please attach the following / EHCP or statement
Appendices (if current)
Last annual/interim review
And any other reports you feel are necessary
Details of expected outcome following a period of tuition
Options / Please tick
Has been permanently excluded and awaiting decision via the Fair Access Panel to identify a new school place?
Has particular social and behavioural difficulties and hasa personalised learning plan: this means that, by arrangement, they do not attend their usual school full time. Joint planning is arranged by school with key professionals to secure an increased access to education?
Has mental health needs and accesses Child and Adolescent Mental Health Services (CAMHS), either as an in-patientor through services provided in the community? A care plan is agreed to reintegrate back into full time education.
Has medical needs other than mental health needs and will return to school when well enough?
Has complex needs and no suitable school place is available. Consultation of appropriate provision is to be carried out?
Is new to the country and awaiting a school place? The child has been referred to the School Admissions Department or SEND, whichever is appropriate.
Has moved from another area and a school place has not been secured; this may include children who are looked after? The child has been referred to the School Admissions Department or SEND, whichever is appropriate.
Before a request for tuition is made all other provision should be explored to meet the pupil’s needs in school.
All pupils in receipt of less than 25 hours of education will be placed onto the Children Missing Education Register and evidence is required to ensure that individual tuition is the most appropriate option for the pupil and the circumstances they are in.
Please give a full account of provision and strategies that have been put in place prior to the request for individual tuition.

Before requesting individual tuition please be mindful that if the request falls outside of the local authority statutory duty to provide individual tuition, there may be a charge for services provided to the referring body.