Learner Referral Form Referring AgencyReferring organisation type: *Select from listLocal AuthoritySchoolSocial CareParent/CarerOtherFunding will be provided by: *Select from listLocal AuthoritySchoolSocial CareParent/CarerOtherIf ‘Other organisation’ – please specifyIf ‘Other funding method’ – please specifyLearner InformationLearner’s full name *Date of Birth *Unique Pupil Number (UPN)Gender (as recorded on school system)First LanguagePhysical or mobility difficultiesParent/Carer 1 Name *Parent/Carer 1 Phone *Parent/Carer 2 NameParent/Carer 2 PhoneHome AddressReferring School InformationAttendance/Progress reports to be sent to (email address)Invoice recipient nameInvoice recipient email addressLearner is currently on roll at (school name)Email Address of DSLSocial WorkerDoes the Learner have a social worker? *YesNoNamePhoneEmail AddressProvision RequiredProvision Type *Animal Assisted Intervention (Therapeutic Outcomes)Alternative Education (Academic Outcomes)BothProposed Start DateLearner HistoryHome Background SummaryLearners InterestsAttitude & BehaviourConcerns relating to exploitation, offending or community safety (optional)Current YOT order? *YesNoIs the student under the care of local authority? *YesNoSEN Needs *YesNoMedical RequirementsDoes the learner have any known medical requirements or allergies? *YesNoDiabetes *YesNoAsthma *YesNoHemiplegia *YesNoEpilepsy/Seizures *YesNoAllergiesYesNoPlease provide the medical requirments or allergy detailsIf the learner requires medications, this will require a separate medicines administering consent form to be completed. (this will be sent on separately to the parent/caregiver)EducationCurrent Attendance (in %) *Current English Level (optional)Current Maths Level (optional)Is the student being entererd for any exams in school? Please list the qualifications and the awarding body below, along with any access arrangements. (optional)School Background Summary (optional)Does the student have an EHCP? *YesNoFile to uploadChoose FileNo file chosenDelete uploaded fileSummary of Current Education Plan (optional)Risk AssessmentIf the school has deemed it necessary to produce a Risk Assessment, please upload it hereChoose FileNo file chosenDelete uploaded fileConfirmationYour name *Your title/role *Your email address *Your contact number *HT/SLT NameHT/SLT Email address for service level agreementWill you or your organisation be responsible for funding this placement? *YesNoBy submitting this referral you confirm that you have read, understood and accept the terms of the Animals in Mind Service Level Agreement for the learner referred. *By submitting this referral you confirm that you have read, understood and accept the terms of the Animals in Mind Service Level Agreement for all learners referred. You also confirm that you are authorised to commit the organisation to the associated costs and responsibilities set out in this document. *Your Signature *Start signing your signature hereYour browser does not support e-Signature field.SubmitSave as DraftPlease do not fill in this field.
