REFERRAL OF A YOUNG PERSON/FAMILY
V1
CF EDUCATION
Offering unconditional positive regard to children, young people and families
FOR SUPPORT WITH REMOTE LEARNING
Note: This form MUST be completed in full. All sections are mandatory.
INFORMATION ABOUT THE REFERRER
Name and status of referrer
Organisation
Authorised telephone number/s
Authorised email address/es
INFORMATION ABOUT THE YOUNG PERSON & CARER
Young person
Date of birth
Address
Telephone numbers
Is the child eligible for FSM?
Parent/Carers – Key contact
Parent/ Carers email (for remote learning purposes)
Is parent/carer aware of the service/ referral?
Is the parent/carer digitally literate? Any other known challenges?
INFORMATION ABOUT THE YOUNG PERSON’S PROFILE AND NEEDS
For any YES response up to date additional details MUST be attached to this referral
Please circle/ underline a response
Is the young person subject to any form of physical / medical care plan?
YES
NO
Is the young person subject to any form of mental health care plan?
YES
NO
Is the young person associated with current or previous legal actions / provisions?
YES
NO
Is the young person associated with current or previous safeguarding concerns?
YES
NO
Is the young person subject to any form of risk assessment
YES
NO
Known challenges with home learning
Engagement during last lockdown
(if pupil was with you then)
NONE
LIMITED
MODERATE
GOOD
EXCELLENT
WORK & EXPECTATIONS
Work set (subjects etc)
Timescales – set and completion
Platform used by school
SUPPORT REQUIRED
Package requested
· Package 1
Set up phone call: introduction to the service, how we can help.
2 weekly phone calls (probs Mon & Weds)
Total support: 9 phone calls
· Package 2
Set up phone call: introduction to the service, how we can help.
3 weekly phone calls (Mon, Weds & Fri)
Total support: 13 calls
· Package 3
Set up phone call: introduction to the service, how we can help.
2 weekly phone calls and 1 face-to-face (virtual if required) session in the home.
Total support: 9 calls and 4 face-to-face sessions
· Package 4
Set up phone call: introduction to the service, how we can help.
2 face-to-face sessions (virtual if required) in the home and 1 call.
Total support: 5 calls and 8 face-to-face sessions
· Package 5
Set up phone call: introduction to the service, how we can help.
2 face-to-face sessions (virtual if required) in the home and 3 calls.
Total support: 13 calls and 8 face-to-face
Area of support required
· Simple ideas to support your child’s reading
· Helping with homework
· Overcoming reluctance to learn at home
· Myth-busting Maths
· Creating a learning space/zone in your home
· Coping with digital resources from school
Please email this referral (and any attachments) to: [email protected]
Or post it to: CF (Education), Delta 1, West Road, Ipswich. IP3 9FH
We put the needs of children, young people and their families and carers at the heart of everything we do.
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