Make a Referral

Making a referral is straightforward. Tell us about the learner, and we'll get in touch to understand their needs and recommend the most appropriate pathway.

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1. Referrer Details

Title*

MrMrsMissMsDrOther

Name

Address

Email*

Phone*

Organisation*

Role (if applicable)

Relationship to Referee*

I am happy to be contacted regarding this referral?

NoYes

2. Individual Details

Date of Birth*

Name

Address

Referral Note

The individual is aware of this referralReferral made in the individual’s best interests

3. Support Being Requested

I am referring for (tick all that apply)*

Alternative ProvisionSEND supportSEMH supportEBSNA / school attendance

1:1 supportOnline / hybrid learningNot sure yet

Other

When is support required?*

Immediately / urgentWithin the next 4 weeksPlanned / future support

Other

Tell us briefly about the young person and what support they need*

4. Additional Information

Is there anything else you feel is important for us to know?

5. Consent & Data Protection

Declaration*

I confirm that I have consent (or appropriate authority) to share this information.I understand this information will be used to assess suitability and contact relevant parties.

Privacy notice

We will only use the information provided to respond to this referral and assess appropriate support. Information will be stored securely and handled in line with applicable data protection legislation. See our Privacy Policy.

6. Preferred Next Steps

Preferred contact method

PhoneEmailMeeting / assessment discussion

Thank you for starting a conversation with us!

Email address

Website

UK Office

Suite 1

Aqueous II

Rocky Lane

Birmingham

B6 5RQ

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