NEET Learner Information Form

Student Referral Form

This form is designed to ensure the safety and well-being of all students and staff through the identification of any safeguarding concerns or risks prior to onboarding a learner. Please complete this form thoroughly to ensure we are able to provide the best support for the learner.
Section 1: Student Information
Full Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender at Birth*

MaleFemale
Preferred Pronouns*
Student Address*

Street Address

Street Address Line 2

CityCounty

Postal Code
Section 2: Educational Background
Last or current school/provision attended*
Is the student still on roll at the above provision?*

YesNo
If you answered no to the above, please detail the reason for leaving the last provision.*
Please detail the date the student last attended the above provision?*

DayMonthYear
Date
What is the student's current year group?*
Has the student been excluded or at risk of being excluded*

Yes - excludedYes - at risk of being excludedNo - never excluded or at risk of being excluded
If yes, please provide details*
Section 3: Safeguarding
Please detail any known safeguarding concerns*
Please detail any history of aggression or behavioural issues*
Please detail any mental health or medical conditions*
Please detail any gang affiliations or associations*
Please detail any substance misuse or utilisation concerns*
Please detail any family or environmental risks*
Please detail any risks to themselves, including self-harm or suicide risks*
Please detail any risks to others, including staff, other students and visitors*
Please detail any past/present/alleged offences or court orders, including any probation or YOT worker involvement*
Section 4: Support Needs
Does the student have an EHCP (Education, Health, Care Plan) in place?*

YesNoHas previously had an EHCPIn the process of applying for an EHCP
Please detail any specific accommodations the student requires including medical conditions.*
Please provide details of any external agencies this student is known to or currently involved with such as CAHMS.*
Please detail any other information you feel Step Forward Tuition needs to know in order to best support the learner. *
Section 5: Placement Details and Expectations
Reason for the referral*
Preferred start date*

DayMonthYear
Date
Expected duration of the placement*
Desired outcomes for the learner*
Any additional information you feel may be relevant to the placement decision
Section 6: Supporting documentation
Please email any and all neccessary supporting documentation to info@stepforwardtuition.co.uk FAO Shantay Roberts. Please ensure the subject line includes the learners full name.

This will enable us to best support the learner, this includes but is not limited to:

- EHCP

- Risk Assessments

- Recent Reports (Educational, Behavioural or Medical)

- Any Intervention Reports

- Any Additional Supporting Documentation
Signature
Full Name of Individual Completing the Application*

First NameLast Name
Position*
Organisation/School you work for*
Email address*
example@example.com
Please sign to advise the above information has been provided to the best of your knowledge and to show you understand the above information will be used to assess the suitability of the learner for this placement.*

Clear
Please date the box below*

DayMonthYear
Date
Should be Empty:

Student Referral Form

Section 1: Student Information

Section 2: Educational Background

Section 3: Safeguarding

Section 4: Support Needs

Section 5: Placement Details and Expectations

Section 6: Supporting documentation

Signature