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: educationadmin@cfeducation.co.uk

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.