Information
Individual Learner Starter Information
*Name of person referring
*
First Name
Last Name
Your Relationship To The Young Person
*
*Your Email
*
*Your Phone Number
*
*Young Person First Name
*
*Young Person Surname
*
Official Name as it appears on birth certificate/passport (if different)
*Name likes to be called (if different)
*
Gender
*
Male
Female
Other (please state in notes)
Gender (Other):
Preferred Pronoun:
Ethnicity:
*Address
*
House Name / Number
Street Address
Town
County
Postcode
Are there any police Markers on the address?
*
Yes
No
Date Of Birth (DD/MM/YYYY)
*
Has the Young Person Got an EHCP?
*
Yes
No
*What Provision Are You Applying For?
*
Primary
Secondary
Post-16
What is the young person's social care status?
*
Child Protection
Child In Need
Child In Care
Early Help
Child Not Open To Social Care
Current / Named Provision?
*
*School Name (If applicable)
Learner School Year (If applicable)
DSL contact name at school (If applicable)
DSL Email address at school (If applicable)
Why is the Young Person being referred?
*
Name of Social Worker / Family Support Practitioner (if Applicable)
Contact email address of Social Worker / FSP
Name / Phone Number & Email of any other Professionals Working With the YP?
Who is the lead professional?
If you require attendance register emails - what email address do we send this to?
Who do we send weekly daily observations to?
Parent/Carer Emergency Contact Details:
*First Name
*
*Surname
*
*Mobile Number
*
*Email
*
*Relationship to young person
*
Any locations of concern relating to the YP / any area or peer mapping held on file?
*
Have Parents/Carers been informed about Pushforward?
*
Yes
No (if no state please why in notes box)
Notes
Learning Difficulties / Health Problems:
Learning Difficulties / Health Problems
*
Yes
No
Primary LLDD & Health Problem Category
*
Please Select
1. Emotional / Behavioural difficulties
2. Multiple disabilities
3. Multiple learning difficulties
4. Visual Impairment
5. Hearing impairment
6. Disability affecting mobility
7. Profound complex disabilities
8. Social & emotional difficulties
9. Mental health difficulty
10. Moderate learning difficulty
11. Sever learning difficulty
12. Dyslexia
13. Dyscalulia
14. Autism spectrum disorder
15. Aspergers syndrome
16. Temporary disability after illness (eg post-viral) or accident
93. Other physical disability
94. Other specific learning difficulties (eg Dyspraxia)
95. Other medical condition (eg Epilepsy/asthma, diabetes)
96. Other learning difficulty
97. Other disability
98. Prefer not to say
99. Not provided
N/A
Additional LLDD & Health Problem Category
*
Please Select
1. Emotional / Behavioural difficulties
2. Multiple disabilities
3. Multiple learning difficulties
4. Visual Impairment
5. Hearing impairment
6. Disability affecting mobility
7. Profound complex disabilities
8. Social & emotional difficulties
9. Mental health difficulty
10. Moderate learning difficulty
11. Sever learning difficulty
12. Dyslexia
13. Dyscalulia
14. Autism spectrum disorder
15. Aspergers syndrome
16. Temporary disability after illness (eg post-viral) or accident
93. Other physical disability
94. Other specific learning difficulties (eg Dyspraxia)
95. Other medical condition (eg Epilepsy/asthma, diabetes)
96. Other learning difficulty
97. Other disability
98. Prefer not to say
99. Not provided
N/A
Additional LLDD & Health Problem Category
*
Please Select
1. Emotional / Behavioural difficulties
2. Multiple disabilities
3. Multiple learning difficulties
4. Visual Impairment
5. Hearing impairment
6. Disability affecting mobility
7. Profound complex disabilities
8. Social & emotional difficulties
9. Mental health difficulty
10. Moderate learning difficulty
11. Sever learning difficulty
12. Dyslexia
13. Dyscalulia
14. Autism spectrum disorder
15. Aspergers syndrome
16. Temporary disability after illness (eg post-viral) or accident
93. Other physical disability
94. Other specific learning difficulties (eg Dyspraxia)
95. Other medical condition (eg Epilepsy/asthma, diabetes)
96. Other learning difficulty
97. Other disability
98. Prefer not to say
99. Not provided
N/A
Learning Funding & Monitoring
LDA
*
N/A
Learner has a Section 193A (Learning Difficulty Assessment LDA)
HNS:
*
N/A
Receives Element 3 Top funding from Local Authority
EHCP:
*
N/A
Learner has an Education Health Care Plan
SEN:
*
N/A
Special Education Needs
Is the young person a Looked After Child?:
*
Yes
No
Risk Control Measures
Had any suicidal thoughts?
*
Yes
No
If yes, details
Ever Self-Harmed?
*
Yes
No
If yes, details
Physical Assault?
*
Yes
No
If yes, details
Verbal Assault?
*
Yes
No
If yes, details
Concerns online?
*
Yes
No
If yes, details
Contextual Safeguarding Concerns (locations/associations)?
*
Yes
No
If yes, details
Illegal drugs?
*
Yes
No
If yes, details
Abscond?
*
Yes
No
If yes, details
Known peer concerns?
*
Yes
No
If yes, details
Weapons?
*
Yes
No
If yes, details
Self-Harm?
*
Yes
No
If yes, details
Suicide attempts?
*
Yes
No
If yes, details
* Learner Interests
What subjects is the learner interested in
*
Vehicle Mechanics
Construction (inc bricklaying, carpentry, plumbing, electrics etc)
Bicycle Maintenance
English & Maths
Sports & Fitness
Drama / Dance
Arts & Crafts
Hair & Beauty
Music Production & Animation
Cooking / Catering
Welding & Fabrication
Photography
Theatre Arts
Animal Care
Bush Craft
Other (state in notes)
Any other information/notes
What are the required outcomes?
*
Cost of Delivery
(Invoices Paid In Advance of Delivery)
*Required Number of Hours Per Week
*
3 - Secondary / Post 16
6 - Secondary / Post 16
9 - Secondary / Post 16
12 - Secondary / Post 16
15 - Secondary
5 - Primary
10 - Primary
15 - Primary
*Who is funding this project?
*
School in Full
LA In Full
LA & School
Other
Other / Notes
Documents
Have you sent to studentinfo@pushforward.uk the latest EHCP?
*
Yes
N/A
Have you sent to studentinfo@pushforward.uk the latest Risk Assessment?
*
Yes
N/A
Have you sent to studentinfo@pushforward.uk any other documentation to assist?
*
Yes
N/A
Pushforward will not be all or substantially all of the Young Person's education and please advise immediately if there are changes to this:
*
Yes
Is any other Alternative Provider involved?
*
Yes (please state in notes who and what days/times)
No
Notes
Any Other Helpful/Useful Information?
I certify that we are happy for a proposal to be prepared for approval, based on the information provided above, and the information provided is accurate to the best of my knowledge:
*
First Name
Surname
T: 0330 818 0186 - E: enquiries@pushforward.uk - Head office: Ground Floor, Unit 6 Hillside Business Park, Bury St Edmunds IP32 7EA
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