Please Return Completed Forms to:
The Heights Alternative Provision Referral Form 2018All sections must be completed before application is processed. Failure to do so will slow down referral.
Details of Young Person
First Name(s) / Gender / Male/ Female
Surname
Ethnicity / First Language / Religion
Start Date
UPN / UCI
ULN
D.O.B / Year Group / 9/10 / 11 / Free School Meals / Yes/No
Address Including Post Code
Telephone Number
Parent / Carers / Emergency Contact
First Name
Surname including title Mr/Mrs/Miss/Ms
Relationship to Young Person
Telephone Number
Address (if different from above please give details)
Emergency Contact Details (needs to be different from above)
Name
Relationship to Young Person
Telephone Number
Referring School
Name of School
School Contact Details
Name
Position
Telephone Number
Attendance / Has this student had exclusions? Yes/No
% Attendance / Number of days
% Authorised Absence / Number of occasions
% Unauthorised Absence
Please give details of any EWO input
Type of Referral
Year 10 Full Time / Year 11 Full Time
Reason for Referral (please explain)
Home Situation (please explain)
Is the young person subject to a Child Protection Plan?
(If yes, please give details of present or past involvement) / Yes / No
Is the young person a “child in our care”
If yes please give details below / Yes / No
Name of Social Worker
Telephone Number
Local Authority
Does the young person have a CAF?
If yes please give details below / Yes / No
Name of lead professional
Organisation
Contact Details
Agencies Involved – please tick
/ Date of Involvement / Named Contact and Telephone number
No Agency Involvement
ELCAS
Children Services and Social Care
Midwife / Consultant
Complex Needs Team
Education Psychologist
YOT
Engage
Lifeline
Young Carers
NSPCC
Other
Give Relevant details of any current involvement of the above
(continue on separate sheet if necessary)
Academic
National Curriculum Level/Teacher Assessment
Key Stage 2 – English Maths
Key Stage 3 – English Maths
Current Levels – English Maths
Reading Age
Spelling Age
CAT Scores
Examination Entries
Please indicate if any of the following apply (delete those that do not apply)
EHCP/Additional Support in or out of class
Main Needs / Secondary Needs
Does the Student display any difficulties concerning
Speech and Language Yes/No
Dyslexia Yes/No
Dyspraxia Yes/No
ASD Yes/No
ADHD Yes/No
Other
Please give details of diagnosis and applied strategies.
If the student has a statement or EHCP the date of the meeting / when this will be discussed with the SEN Officer?
Do parents have any concerns regarding any SEND issues?
Young Persons Interests or hobbies
Please give details
Courses interested in
Hair & Beauty / Childcare / Construction
Sport & Leisure / Expressive Arts / Media
Have the young person’s parents/carers been contacted and are they in agreement with this referral? / Yes / No
Does the Young Person agree with the referral? / Yes / No
Please comment
What are the intended outcomes of the placement? In other words how will we know if the placement has been successful?
Additional Documentation Required / Included – please tick
1. Copy of attendance record
2. Up to date curriculum information (including coursework)
3. Exclusion history with reasons
4. Copies of EP reports, medical reports and information from other agencies.
5. Copy of EHCP/IPRA if appropriate
6. Copy of TAC plans