Referral Form 2025
Which provision would you like to refer the learner to?
Select Alternative provision 121 College 121 NESTA vocational centre Bolton NESTA vocational centre Wythenshawe Atlas Wythenshawe
Year group
Select Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 Year 13 Year 14
Does the young person have an EHCP?
Select Yes No
Does the young person receive Free School Meals (FSM)?
Select Yes No
Ethnicity
Select White - British White - Irish White - Any other White background Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Any other mixed background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Any other Asian background Black or Black British - Caribbean Black or Black British - African Black or Black British - Any other Black background Other Ethnic Groups - Chinese Other Ethnic Groups - Any other ethnic group
Medical & Physical Health Needs
Select Asthma Epilepsy / Seizure disorder Diabetes (Type 1 / Type 2) Allergies (mild) Severe allergies / Anaphylaxis Hearing impairment Visual impairment Heart condition Respiratory condition Chronic fatigue / ME Hyper-mobility / joint conditions Physical disability affecting mobility Continence / toileting needs Gastrointestinal condition (e.g. Crohn’s, IBS) Chronic pain condition Migraines Medication required during the day Other physical health need (specify)
Mental Health / Emotional Needs
Select Anxiety disorder Depression Trauma history / ACEs PTSD / complex PTSD Panic disorder Emotional dysregulation Eating difficulties or disorder Self-harm history Suicidal ideation (current or past) Behaviour linked to distress or unmet need Other emotional/mental health need (specify)
Primary area of need (inc. diagnosis)
Select ADHD Autism behavioural difficulties EBD SEBD SEMH development delay down syndrome dyscalculia dyslexia dyspraxia learning disability sensory impairment speech and language visual impairment other additional needs
Level of need
Select Cared for child child in need child protection early help post looked after child universal
Has the young person had any exclusions?
Select Yes No
If yes, please give details
Barriers to Learning/Engagement
Tell us about the student/learner’s personality, interests and aspirations.
What is their main barrier to learning and engagement?
Select Behavioural Emotional (inc. mental health) Social (inc. environmental) Academic (inc. cognition & learning) Physical (inc. sensory needs)
Does the student/learner experience conflict with peers and/or show signs of holding grudges?
Select Yes No
If yes, please describe the nature of these conflicts and any patterns you've noticed.
Is this mentioned in their EHCP or other documentation?
- Select - Yes No
(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?
Select Yes No
Is the student/learner vulnerable to exploitation, or gender-based violence (TF-GBV)?
Select Yes No
Is this mentioned in their EHCP or other documentation?
Select Yes no
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?
Please confirm the arrangements for the young person when they are not in our provision
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.
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