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referral form

To make a referral to The ReConnect Programme, please complete the online referral form below with as much information as you have available and all relevant documentation. We aim to respond to referral submissions in a timely manner however if you have not received a confirmation of submission by email within five working days, please email admin@ReConnect1-1.com.​

Alternatively, please download and complete the referral form. Please email this form and all supporting documentation to Admin@ReConnect1-1.com Titled: Referral and your young persons initials.

Referrers Information:

About Your Referred Individual:

Gender
Date Of Birth
Day
Month
Year
Has The Individual Got An EHCP?

Parent/Carer Contact Details:

The Provision

Where Would You Like This Programme To Be Held?
Is Core Subject Tutoring Required?
What Specialisms is The Individual Interested In?

Learning Difficulties / Disabilities

Specific Learning Difficulties (SpLD)
Neurodevelopmental Disorders
Intellectual and Cognitive Disabilities
Social, Emotional, and Mental Health (SEMH) Needs
Physical Disabilities with Associated Learning Challenges
Medical and Genetic Conditions Affecting Learning

Funding & Monitoring

Please Select

Risk Assessment

Please Select Any Of The Following If They Are Relevant To The Individual You Are Referring To Us And List Full Details Below.

Required Documents

Please upload the following supporting documents:

Declaration

ReConnect 1-1 can not account for the entire educational provision for an individual who is under 16. Please tick the box below to state that you have read and understand this.

I can confirm that I agree to ReConnect 1-1 proceeding with preparing a draft proposal for approval based on the details provided above, and that, to the best of my knowledge, the information given is accurate.

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