Daytime 1:1 Provision Referral Form

Section 1: The child being referred

Child’s Name (please use a separate form for each child referred)

Date of birth

Gender

School attended

Does the child have a statement of educational need?

Parent/Carer’s name

Address (please include full postcode)

Home number

Work number

Mobile number

Email address

Additional background information (please use additional sheet if required or attach relevant CAF)

Please list all targets and desired outcomes

Section 2: The referring agency

Name of referring agency and contact details of person making referral

Name

Position

Email address

Contact number

Name and contact details of finance department for invoicing purposes

Name

Position

Email address

Contact number

Authorised by: (person who is authorised to accept financial responsibility for the service)

Other agencies involved

Section 3: The service requested

All 1:1 services are undertaken on a ’spot purchase’ basis and payment agreed in advance

1:1 Support Day Time Service - This service is available during school hours (term time only). Sessions are available between the hours of 8.30am and 3.00pm.

Start date

Review date

Preferred days and times: We will try our best to accommodate you but will be determined by staff availability.

Monday

Tuesday

Wednesday

Thursday

Friday

Authorised by (name)

Signature

Date

Section 4: Payment Arrangements

Scale of Charges:
Sessions are charged at £35.00 per hour
3 hour session: £105.00 (including lunch and activities)
4 hour session: £140.00 (including lunch and activities)
5 hour session: £175.00 (including lunch and activities)

Section 5: Contact details

Glenys James Mentoring Project Coordinator
[email protected]
020 7183 5120 ext. 899

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