Local Authority - Young Person Referral Form

Which service are you referring from?

Name of your service:

Official service address:

Service contact number:

Date of this referral:

Who is making this referral?

Your Full Name:

Your Contact Number:

Your Email Address:

Has Student Had An Induction?:
YesNo
If yes, what date did the student have an induction?:

Who Is Being Referred?

Student Name:

Student's DOB:

Students Ethnicity:

Student's Home Address:

Student Contact Number:


Emergency Contact Name:

Emergency Contact Relationship to Student:

Emergency Contact Number:

Please tick which of the following workshops the student would like to attend:

Cycle TechnicianArt and DesignBusiness and IT

Please Tell Us All Risk Factors

Is the Student on an EHCP:
YesNo

Any Known Allergy Risk?:
YesNo
If yes, please give detail:

Any Known Risk To Staff Members?:
YesNo

Any Known Risk To Self?:
YesNo

Is The Student Taking Medication?:
YesNo
If yes, please detail medication:

Does The Student Have Any Diagnosed Conditions?:
YesNo
If yes, please explain Conditions:

Does The Student Have Any Behaviour, Attitude or Motivational issues?:
YesNo
If yes, please tell us more:

Any Other Personal Risks or Concerns we should know?:

Consent for Photographs permitted internet, newsletters, magazines in keeping with safeguarding?:
YesNo
Please detail below any positive factors about the student, including hobbies, interests etc.:

When Would You Like The Referral To Start, and When is The Student Available?

When Would You Like The Referral To Start?:

How Many Days Per Week Would You Like Your Student To Attend?:

Please tick which of the following days would the learner be able to attend regularly?
TuesdayWednesdayThursdayFriday

Feedback and Reporting Contacts

Please provide all email addresses you would like us to send feedback and reports to:

Billing Information

Please Provide A Contact Name For A Member Within Your Accounts Department:

Accounts Department Telephone Number:

Please Provide At Least Two Email Contacts For Billing Purposes:

If The Student Has An EHCP - please attach a copy here:
Please attach any risk assessments here:

It is important that we receive the correct information to ensure the correct levels of knowledge and support are in place i.e. 1 to 1 supervision and general safeguarding procedures.

Please Note: Once referred if the individual's behaviour does not match the risk factors detailed on this referral form, you will be contacted, this may result in fees being altered to match the Risk factors, Risk Assessments or Educational Health Care Plan needs.

Please prove you are human by selecting the Cup.