Referral Source (School Information)
School Name:
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Referrer’s Name & Role:
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Contact Number:
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Email Address:
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Date of Referral:
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Student Information
Full Name:
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Date of birth:
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Year Group:
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Address:
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Parent/Carer Name(s):
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Parent/Carer Contact Number:
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Parent/Carer Email:
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Reason for Referral
(Tick all that apply)
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■ Behaviour Support
■ Attendance Concerns
■ SEMH (Social, Emotional, Mental Health)
■ Alternative Provision
■ Other (please specify):
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Brief summary of concerns and reason for referral:
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Support Already in Place:
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Desired Outcomes from Placement at Legacy Youth Academy
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■ Improved Engagement
■ Positive Behaviour Change
■ Personal Development
■ Physical Fitness / Wellbeing
■ Other:
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Additional Information (Medical conditions, SEN, safeguarding, EHCP, etc.)
*
Consent
Has parent/carer been informed of this referral?
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Yes
No
Has student consented to being referred?
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Yes
No
Signatures
*
Clear
Date
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SUBMIT