Schools & LAs Referral Form How can we help you?(Required) I have a specific young person(s) I am looking to refer I want to learn more about what Powertutors can offer What type of referrer are you?(Required)Please selectI'm a Local authority, school, or other institutionI'm a parent, carer, or guardianOtherYour institutionName of your institution(Required)E.g. Dove School or Cardiff Council Tick the category that best describes your institution(Required) LA Maintained School Academy PRU Specialist School Care Home Private company Government body Which LA team are you referring from?(Required) CME Inclusion / AP Medical Refugee and Asylum Seeker SEND Virtual School Youth Offending Other Your detailsName(Required) First Last Email address(Required) Phone Number(Required)Which of these best describes your position?(Required) SEND case worker/officer SEND Team Manager Commissions Team SENDCO Headteacher / Principal Assistant Head Deputy Head Class Teacher Designated Safeguarding Lead Pastoral Team Inclusion Lead DSL Senior Leader Inclusion Coordinator Other Please specify your specific job title(Required)About the child/young personBy providing detailed information’s in this section will enable us to quickly find a suitable tutor to re-engage the individual you are referring to. Child's/young person's name(Required)If their name cannot be disclosed, please provide initialsChild's/young person’s DOB Day Month Year How does the child/young person identify their genderIs support due to be online or F2F?(Required)Please selectOnlineFace-to-faceEitherAddress(Required)Please provide the full line of address (where support will need to be carried) Street Address Address Line 2 Town/City County Post Code Child's/young person’s main SEND area of Need?(Required)Please selectCognition & interactionCognition & learningSocial, emotional, and mental health difficultiesSensory and/or physical needsHours per week required(Required)Minimum of 5 hours for Face-to-Face bookingsList the specific support needed(Required)i.e. naming the specific subjects, if unaware yet on what you would like to allocate, please specify to be discussed via phone. Child's/young person’s school year/level?(Required)EHCP UploadIf the young person has an education health care plan in place, please upload a copy of the EHCP here if possible (and any other useful information you can share at this stage). Drop files here or Select files Accepted file types: doc, docx, pdf, png, jpeg, jpg, Max. file size: 2 MB, Max. files: 5. Is the child/young person currently enrolled in any qualifications or do they have any upcoming examinations that you require us to prepare them for?Please provide details such as: awarding body, course codes, dates of examinations or coursework and predicted grades.If you have more children/young people to add, tick yes and we will call you Yes, please call me to discuss other child referrals Meeting RequestOur team are always here to help! Would you like to book in up to 30 minutes to discuss your new enquiry with our team?Would you like to book a meeting?(Required)Please SelectYesNoPreferred Meeting Date(Required) Day Month Year Preferred Meeting Time(Required) Hours : Minutes AM PM AM/PM EmailThis field is for validation purposes and should be left unchanged. Δ
