Local authority referral form

Please complete the 4 part form below.

Part 1. Student details
Part 2. School details
Part 3. School experience
Part 4. Agreement and checklist

Part 1. Student details

Name

Address

Postcode

Date of birth

Year group

Gender preference

Ethnicity

UPN

Local Authority

Current Attendance (%)

Parent / guardian / carer details

Name

Relationship to student

Address

Postcode

Mobile number

Home number

Permission given?

Does the student have an EHCP?

Which Local Authority has responsibility for the EHCP?

Is the student under assessment?

Upload file

Is the student undergoing CAMHS supervision / referral?

Does the student have a personalised risk assessment / behaviour plan / communication plan?

Upload file

Does the student have a named social worker?

Mobile number

Please provide the latest PEP and LAC review / SGO documents

Upload files

Does the student have a diagnosis of a Special Education Need?

Secondary need

Part 2. Referrer details

Person making referral

Role

Mobile number

Finance contact

Name

Mobile number

Is the young person currently on roll at a school or other provision?

School / provision address

Is the school part of a MAT?

Trust name

Contact name

Phone number

Part 3. School experience

Please provide a brief history of the students school experience

Has the student had a permanent exclusion?

Student's most recent attendance %

Please indicate in detail key learning, social, emotional or behavioural needs along with strategies already tried with the student or interventions they have accessed

What are your expectations for the student whilst at Navigators?

Short term (half term)

Medium term (full term)

Long term (annual term)

Part 4. Agreement and checklist

Preferred start date

Projected end date

Days per week

If the assigned member of staff is off work we will endeavour to provide an alternative and suitable member of staff. If a parent / carer refuses this due to the possible issues of the change, no refund will be payable.

I agree to the payment policy below and have provided all required information.

Navigators operate a payment in advance policy

Please confirm you agree to pay the agreed amount for the agreed period of the placement, within 14 days of the date of invoice, at the start of the placement (no refund due to day exclusions, illness or appointments). A SLA will be sent to the finance contact prior to the start of the planned programme.

PO Number

By submitting this application form you are agreeing to the terms of the commission agreement and payment requirements.