Hi,

Thanks for getting in touch about our Alternative Provision. Please complete the below form with as much information as possible so that we can work out what support the child or young person you are referring may need and develop an action plan to help.

This form should be completed by educational establishments as this service falls within the remit of providing suitable alternatives to mainstream education.

If you would like to discuss anything specific before you complete this form, please call Becki on 07445 209 725 or email [email protected].

Email *

First Name

Last Name

What is your contact email address?

Phone *

Please provide the name of your establishment

Please can you provide details about your role?

How many children are you seeking support for?

Are you aware that this is a paid for service and do you have funding available?

Are any of the children you are referring Looked After?

Please tell us about child 1 (inc. Full name, DOB, UPN, current diagnosis - if applicable, specific concerns, attendance record, EHCP status & what other provision is already in place)

Please tell us about child 2 - as above (if applicable)

Please tell us about child 3 - as above (if applicable)

Please tell us about child 4 - as above (if applicable)

Additional Children to Refer?

If you have more than 4 children to refer to this provision, please complete a further referral form.

Many thanks

Which day of the week would work best for the child(ren) you are referring?

Do any of the children you are referring have EHCP's?

Do any of the children you are referring have any other plans or support in place that you haven't mentioned?

Please let us know how you found us

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