Referral Form

If you need help from The Educatch Charity to support a young person, please fill in the form below or download the form by clicking on the button:

Date of Referral

YYYY

Name of Young Person

First Name

Last Name

Date of Birth

YYYY

Parent/Carers name(s):

Address with postcode:

Telephone Numbers:

Home

(###)

###

####

Mobile

Work

What are the learners’ Special Educational Needs (if any)? If possible, please attach most recent EHCP/Review

Medical needs:

Other information e.g. Behavioural concerns/ recent exclusions etc.

SEN Case worker contact details (if applicable):

Social worker/any other professional contact details (If applicable):

Services Offered

Bespoke educational support/ tuition (please specify subjects) attendance, engagement, emotional and behavioural

Family Support Service

SEN - Occupational therapy/ SALT / Mental health

Date

Desired start date for support to commence:

YYYY

Fees: All services are delivered on a 1:1 basis @£36/hr