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Schools/la referral form

Your Email

About the CYP

CYP First name

CYP Last name

Likes to be known as

Gender

Male

Female

Other

Date of Birth

Day

Month

Year

Ethnicity

Religion

What provision(s) is the CYP currently attending/registered with?

Areas of Need

Neurodevelopmental & Learning

ASD / Social Communication Needs

ADHD / Attention and Regulation Needs

Sensory Processing Differences

Specific Learning Difficulty (e.g., dyslexia, dyscalculia)

Global Developmental Delay

Speech, Language & Communication Needs

Working Memory or Processing Speed Difficulties

Emotional, Social & Mental Health

Anxiety (including school-based anxiety or phobia)

Emotion Regulation Difficulties

Low Mood or Depression

Attachment or Developmental Trauma

Experience of ACEs (Adverse Childhood Experiences)

Self-harm or Suicidal Thoughts

Difficulty trusting adults / hypervigilance

Peer relationship challenges

Low self-esteem / identity needs

Educational Engagement

Long-term non-attendance / School refusal

Currently out of education

At risk of exclusion

Has been permanently excluded

Disengaged from classroom learning

Difficulty coping in mainstream setting

Needs alternative / reduced timetable

Needs 1:1 or 2:1 support to access learning

Functional & Daily Living

Difficulties with transitions or changes in routine

Sleep difficulties

Toileting / continence issues

Eating or feeding concerns (e.g., ARFID)

Delayed play or social development

Communication difficulties (verbal/non-verbal)

Requires high levels of adult scaffolding

Safety & Risk

History of harm or safeguarding concerns

History of running away / absconding

Risk-taking behaviours

Experiences dysregulation that can lead to aggression

Currently on a Child Protection or Child in Need plan

Previously on a Child Protection or Child in Need plan

Family & Contextual Needs

CYP is looked-after or previously looked-after

CYP is in foster care or kinship placement

Early Help Involvment

Social Worker Involvement

Housing instability or in temporary accommodation

Parent/carer needs support with CYP's behaviour at home

Young carer

CYP is home educated due to unmet need in school

Please specify any known health needs below:

What programme is required?

Wednesday Group Respite 10:00-15:00

Thursday Group Respite 10:00-15:00

1:1 Mentor Support (Days and hours to be arranged)

2:1 Mentor Support (Days and hours to be arranged)

With Bespoke Tuition

Unsure at the moment

Education, Health & Care Plans and Other Documentation

Does the CYP have an EHCP?

Yes

No

In Progress

Is there anything else we should know about?

Long answer

Preferred Start Date

Day

Month

Year

End Date (if known)

Day

Month

Year

Parent/Carer Information - parents are required to complete a registration form upon offer of placement

Parent/Carer's Full Name 1

Parent/Carer's Contact address

Parent/Carer's Contact Number

Parent/Carer's Email

Does this parent have Parental Responsibility?

Yes

No

Parent/Carer's full name 2

Parent/Carer's Contact address

Parent/Carer's Contact Number

Parent/Carer's Email

Is the parent aware of this referral?

Yes

No

Does this parent have Parental Responsibility?

Yes

No

About the referrer

Name and position

Contact phone number:

Contact Email:

How did you hear about us?

The Willows provides up to 15 hours weekly as a supplement to main education. We are not the sole provider. I will inform you if this changes.

Yes

Signature

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We also accept private referrals - please get in touch for more information