Referral for Home Tuition Only

Please ensure that all relevant fields are completed.

	Legal First Name	Legal Last Name	Date of Birth	NC Year	UPN	ULN	% Attendance

GenderMaleFemale

Ethnicity


Other (Please specify)

	Title	Legal First Name	Legal Last Name	Relationship

	Mobile Number	Work Number	Home Landline Number	Email Address	Postal Address	Pupil's Address (if different)	Post code

Are the parents/carers fluent in English in order to understand the induction process?YesNo

Is an interpreter required?YesNo


If Yes, Please Describe Language:

Present / Previous School(s) (Admission and Leaving dates)
	Previous School	Admission Date	Leaving Date	Note

	Previous School	Admission Date	Leaving Date	Note

School Contact Name School Contact Tel. No. School Contact Email Address Referred by: Referral Date: Date Referral Received By The Helix :


Other

Duration / Destination / Plan

e.g. Is an EHCP being requested? Is tuition required inside or outside the home environment

For Key Stage 4 pupils:
	GCSEs/other courses being studied (with exam boards): What coursework has been completed?	Is the student entitled to Access Arrangements?	If so, have Access Arrangements been applied for?
Please state examination boards. Coursework & Access Arrangement details (where applicable)

Professionals known to be involved at start of tuition:
	Children’s Services – Professional Details	Youth Offending Team – Professional Details	Contact number:	Email:	Has the attached professional been made aware of this referral?
Please note this information must be entered & information shared prior to the pupil starting at The Helix.

Stage of Plan:Early HelpChildren In NeedChild Protection


Other


Please Enter Attached Professional Full Name and Contact Details

Please Select Options AvailableFree School MealPupil PremiumEALCLA (Please Provide Local Authority Below)


Home Local Authority

Has the pupil been referred regarding Attendance concerns?YesNo


Professional referred to:

Medical
	NHS Number	Medical Surgery Address and contact details	GP Name	Medical Notes

SEN Status
	Education, Health and Care Plan	From Date	Until Date	Notes

	SEN Support	From Date	Until Date	Notes

	Monitoring	From Date	Until Date	Notes

Educational Needs
	Type	From Date	Until Date	Notes

	Type	From Date	Until Date	Notes

	ENG HOURS	MATH HOURS	SCIENCE HOURS	OTHER HOURS
SENARS
Buyback

Has the pupil received E-Safety sessions at school?YesNo

Select Date Achievement Log, Behaviour Log, Risk Assessment, Exclusion Log, Education, Health & Care Plan, Recent PEP No file chosen

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