Our Referrals

Please complete the 5 part form below.

Referral Form 2025

Which provision would you like to refer the learner to?

Referrer

Name of referrer

Role of Referrer

Home School/Former School

Local Authority

Area within Local Authority (if relevant)

Student/Learner

Full name of student/learner

Year group

Date of birth

Address

Parent/Carer

Contact Number

Does the young person have an EHCP?

ULN/UPN:

Does the young person receive Free School Meals (FSM)?

Ethnicity

Medical diagnosis/needs

Medical & Physical Health Needs

Other

Mental Health / Emotional Needs

Other

Primary area of need (inc. diagnosis)

Level of need

Social Worker contact (if applicable):

Early Help contact (if applicable):

CAMHS worker contact (if applicable):

Youth Justice contact (if applicable):

Current attendance %

Has the young person had any exclusions?

If yes, please give details

Attainment

Alternative Provision

KS1 Phonics

Average KS2 Score

College

GCSE English

GCSE Mathematics

Functional Skills

Barriers to Learning/Engagement

Tell us about the student/learner’s personality, interests and aspirations.

What is their main barrier to learning and engagement?

Does the student/learner experience conflict with peers and/or show signs of holding grudges?

If yes, please describe the nature of these conflicts and any patterns you've noticed.

Is this mentioned in their EHCP or other documentation?

(We will not agree to this placement until we have triangulated your response to this question).

Help us to tailor their support strategies - what does the student/learner find most challenging and how do they typically respond to these challenges?

Is this mentioned in their EHCP or other documentation?

Is the student/learner vulnerable to exploitation, or gender-based violence (TF-GBV)?

Is this mentioned in their EHCP or other documentation?

What do they worry about most, in or out of their provision?

Please include any safeguarding concerns or disclosures.

Finally, what are your short/medium goals for this student/learner?

Short term

Medium term

Preferred start date

Preferred end date

Days per week

Monday

Tuesday

Wednesday

Thursday

Friday

Please confirm the arrangements for the young person when they are not in our provision

Our terms and conditions

I understand and agree that the alternative provision programme offered by Navigators, is part-time offer and as the commissioner I am responsible for providing the additional hours of entitled education provision 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 abide by the Navigators published term dates and to make payments in accordance with the specified payment schedule

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

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.

Document upload checklist:

Latest school progress report
EHCP
Risk assessment
LAC review
PEP
Social care reports
Education psychologist report

Failure to provide these may result in a delay in the offer.