Refer | Reach Alternative Ed

Refer a Student

Please make sure to fill out all the details below.

Student Name

First Name

Date of Birth

Gender

Last Name

Key Stage

School Year

Ethnicity

Parent(s)/Carer(s) Details

First Name of Parent(s)/ Carer(s)

Parent(s)/ Carer(s) Phone Number

Last Name of Parent(s)/ Carer(s)

Parent(s)/ Carer(s) Mobile Phone Number

Current Address

House/ Flat Name/ Number

Street Address

City

Region/State/Province

Postal / Zip code

If so, please insert Address and Carer details (if different from above)

Mental Health Concerns?

Is there an individual risk assesment/ safety plan in place?

Current Education Provider / School Provider / School address & contact number

Current school contact, position & contact details *

Previous School 1

Previous School 2

Referrer contact, position & contact details (if different from current school)

Other allocated agencies

Current education needs of student / EHCP/ Statement?

Are there any special dietary requirements?

History of attendance in education

Details of health related difficulties (if any)

Details of Disabilities (if any)

Peer group relationships

Pupil – staff relationships

Home – school relationships

The reason for exclusion from school (if applicable)

Purpose of placement - Target/ Aim/ Support?

Any other supporting information (history / current needs of student).

Funders Name/ Contact Details (if applicable)

Name

Email Address

Please score the student on the following REACH attainment objectives

Any other additional information you would like to add regarding the attainment objectives?

Details of Person Submitting Form

This is required so that we may get in contact with you.

First Name

Best Number for Contact

Last Name

Email Address

Thankyou for your submission. We will be in contact with you shortly.

Creating Safe Connections & Environments that Promote Development