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referral form

To make a referral, please complete the online referral form with a much information as you have available and send all relevant documentation (EHCPs, Risk Assessments, ...) to admin@reconnect1-1.com

Alternatively, please download a form from the links below and send it with supporting information to admin@reconnect1-1.com

Referral Form - PDF

Referral Form - Word

Referral From - Pages

Referrers Information:

Name of Referrer*

Role / Position / Relationship To The Referred Individual

Email Address*

Phone Number

About Your Referred Individual:

First Name*

Last Name*

Gender

Male

Female

Other

Gender (if other)*

Preferred Pronoun

Ethnicity

Address

Date Of Birth

Day

Month

Year

Has The Individual Got An EHCP?*

Yes

No

Current Provision*

School Name

Please List Any Other Professionals Currently Working With The Individual

Emergency Contact Details:

Name*

Mobile Number*

Email Address:*

Relationship To The Referred Individual*

The Provision

How Many Hours A Week Are Required? (Minimum 1.5 hours Maximum 15 hours)*

Who Will Be Funding This Programme? School, Local Authority, Private, ...*

What Are The Required Outcomes For The Individual?*

Where Would You Like This Programme To Be Held?*

Instrumental Studios, 12 Looms Lane, Bury St Edmunds

Specialist Facilities

Online

At Individual's Home

A Blend Of All Of The Above Options

Is Core Subject Tutoring Required?*

English

Maths

Science

Languages

Humanities

What Specialisms Is The Individual Interested In? *

Mechanics

Sports & Fitness

Bush Craft & Survival

Theatre & Performance

Audio Production

Vocal Production

Music & Instrument TuitionVocal Production

Cooking & Hospitality

Construction (Including Bricklaying, Carpentry, Plumbing, Electrics)

Dance

Animation

Graphic Design

Visual Arts

Crafts

Hair & Beauty

Photography

Film Making

Ornithology

Water Sports

Biking (MTB, Jump Biking, BMX)

Mixed Martial Arts (MMA)

Climbing / Bouldering

Other

Learning Difficulties / Disabilities

Specific Learning Difficulties (SpLD)

Dyslexia

Dyscalculia

Dysgraphia

Dyspraxia

Other

Neurodevelopmental Disorders

Attention Deficit Hyperactivity Disorder (ADHD)

Autism Spectrum Disorder (ASD)

Speech, Language, and Communication Needs (SLCN)

Sensory Processing Disorder (SPD)

Other

Intellectual and Cognitive Disabilities

Global Developmental Delay (GDD)

Moderate Learning Disability (MLD)

Severe Learning Disability (SLD)

Profound and Multiple Learning Disabilities (PMLD)

Other

Social, Emotional, and Mental Health (SEMH) Needs

Emotional and Behavioural Disorders (EBD)

Attachment Disorder

Other

Physical Disabilities with Associated Learning Challenges

Cerebral Palsy (CP)

Muscular Dystrophy

Epilepsy

Other

Medical and Genetic Conditions Affecting Learning

Down Syndrome

Fragile X Syndrome

Fetal Alcohol Spectrum Disorder (FASD)

Other

Funding & Monitoring

Please Select

High Needs Element 3

Special Educational Needs

Section 193A - Learning Difficulty Assessment

Looked After Child

EHCP (Education Health Care Plan)

Other

Risk Assessment

Please Select Any Of The Following If They Are Relevant To The Individual You Are Referring To Us And List Full Details Below.

Verbal Assault

Physical Assault

Weapon

Issues With Online Activity

Safeguarding Concerns

Absconding

Illegal Drugs

Social Concerns (Peers, Societal, ...)

Self Harm

Suicide Attempts

Other

Required Documents

Please use the tick boxes below to check you have sent us all the documents we will require. Documents should be sent to admin@reconnect1-1.com

EHCP

Risk Assessment

Any Other Relevant And Helpful Documents Available

Other

Declaration

ReConnect 1-1 can not account for the entire educational provision for an individual who is under 16. Please tick the box below to state that you have read and understand this.

Yes

I can confirm that I agree to ReConnect 1-1 proceeding with preparing a draft proposal for approval based on the details provided above, and that, to the best of my knowledge, the information given is accurate.

Signature

Sign in the box or use the keyboard to type.

Signature field is empty.

Name*

Contact

Email: admin@reconnect1-1.com

Phone: 07599 035520

12 Looms Lane,

Bury St Edmunds,

IP33 1HE

Request More Information About The ReConnect 1-1 Programme

First name*

Last name

Phone Number

Email Address

I Would Like To Receive More Information About The ReConnect 1-1 Programme By*

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Email

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