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To complete a referral to our Alternative Provision service, please complete the details as needed. The Referrer should complete this with the parent present or with verbal permissions granted for consent.

Child's date of birth
Day
Month
Year
Safeguarding status:
Proposed start date
Day
Month
Year
Proposed end date
Day
Month
Year
Choose a Learning Package - please note we may facilitate some small group sessions, alongside one to one, if we believe that these can contribute meaningfully towards positive SEMH outcomes, and/or meeting learning objectives *

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

RISK ASSESSMENT


HL = Highly likely; existing evidence leads staff to conclude that the behaviour is more likely than not to occur again.


L= Likely; there is a possibility that the behaviour may occur again


U = Unlikely; but behaviour has occurred before

Do we need to attend a PEP or Annual Review meetings?
Yes
No
Unsure
What days/times are you available during school hours? (9am-4pm)
Is there parental/guardian consent for (please tick the box for yes, leave blank for no or tick no to all of the above):
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Pricing:

£55 + VAT for 1:1 tuition

£40 per hour small group tuition


Once we receive this information, we will get back to you with proposed hours and a suitable package.

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