Alternative provision referral form.
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Email *
Referral made by
Relationship to child *
Date of referral *
MM
/
DD
/
YYYY
Contact details for person making the referral (Name, address, phone number and email address) *
Designated Safeguarding Lead (name, phone number and email) *
Attendance Contact (name, phone number and email) *
Has consent been sought by parents/guardians? *
Name and address of parents/ guardians *
Name of child/ initials if preferred *
Date of birth *
MM
/
DD
/
YYYY
Is the child EAL? Will they require additional support while at Verbatim? *
Is the child in receipt of free school meals? *
Pen portrait (brief history of school, medical and home) *
Pen portrait from parents/guardian (significant life events and key information) *
Concerns *
Best hopes/ targets for AP. ( Including focus of support, ideal hours, days and start/end date.  Please note we can only offer up to 12 hours) *
How are needs currently being met? *
Does this child currently have a Risk Assessment or Behaviour Support Plan? (please give brief outline) *
Are there ways in which the child's needs are not being met in their current setting? *
Child's strengths *
Child's weaknesses *
Does this child currently have an EHCP in place? (Please give primary SEN and additional needs as stated on their EHCP as well as contact details of the EHCP Coordinator) *
Is this child a Child in Care/LAC, Refugee or Unaccompanied Asylum Seeker? *
If relevant, Virtual School Children in Care Advisor name and email. *
Is this child open to Social Care? *
Is the child a young carer? *
Is the child from a Gypsy, Roma or Traveller community? *
Please list any professionals/agencies involved with this child that haven't already been noted previously. *
Any other relevant information *
A copy of your responses will be emailed to the address you provided.
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