Compass AP Child Referral FormPlease complete to apply for Alternative Provisioning with Compass APPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Provision Details – Step 1 of 7 Would Requirements pupil Provision Required *Provision RequiredPrimarySecondaryPost 16AdultNot ApplicableStyle of Provision/Outreach *Style of Provision/OutreachAlternate ProvisionPost NEETMentoringGroup InterventionNot ApplicablePreferred Number of Hours Number of Hours: 12PLEASE NOTE: For under 16 years old the MAXIMUM is 18 hours per weekNextName *FirstLastDate / Time *Date of BirthGender *GenderMaleFemaleNon-binaryNot ApplicableFirst Language *Year Group *Year Group7–8 Year 3 Key Stage 28–9 Year 4 Key Stage9–10 Year 5 Key Stage 210–11 Year 6 Key Stage 211–12 Year 7 Key Stage 312–13 Year 8 Key Stage 313–14 Year 9 Key Stage 314–15 Year 10 Key Stage 415–16 Year 11 Key Stage 416–17 Year 12 (Lower 6th) Key Stage 517–18 Year 12 (Upper 6th) Key Stage 5Not ApplicableUPN NumberChild Protection Status *Child Protection StatusChild in Need (CIN)Child Protection Plan (CPP)Looked After Child (LAC)Child Subject to a Supervision OrderChild Subject to a Care OrderChild Subject to a Special Guardianship Order (SGO)Not ApplicableCAHMS Diagnosis *CAHMS DiagnosisAutism Spectrum Disorder (ASD)Attention Deficit Hyperactivity Disorder (ADHD)Anxiety DisordersObsessive-Compulsive Disorder (OCD)DepressionBipolar DisorderPost-Traumatic Stress Disorder (PTSD)Attachment DisordersOppositional Defiant Disorder (ODD)Conduct Disorder (CD)Eating Disorders (e.g., Anorexia, Bulimia, ARFID)Psychosis (including Schizophrenia)Self-Harm & Suicidal IdeationTourette’s Syndrome & Tic DisordersSensory Processing Disorder (SPD)Not ApplicableFSM *FSMYesNoNot ApplicableSEN Status *SEN StatusSEN Support (England, Wales)Education, Health and Care Plan (EHCP) – EnglandIndividual Development Plan (IDP) – WalesNot ApplicablePlacement Plan *Placement PlanYesNoNot ApplicableLAC *LACYesNoNot ApplicablePrimary Need *Primary NeedCommunication and Interaction (C&I)Cognition and Learning (C&L)Social, Emotional and Mental Health (SEMH)Sensory and/or Physical Needs (S&P)Behaviour ManagementNone of the AboveNot ApplicableCurrent Risk Assessment In Place? *Current Risk Assessment In Place?YesNoNot ApplicableMedicationMedical Diagnosis or DisabilitiesDietary RequirementsPreviousNextName *FirstLastEmailPhone *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodePreviousNextName of School or Council (If Applicable) *Phone *Pupil Current Year Attendance % Selected Value: 100Pupil Previous Year Attendance % Selected Value: 100Current Provision *Current ProvisionAttend Full TimeAttend Part TImeFully In ClassPartially In ClassNot In Class1:1 Full Time Support1:1 Partial SupportAble to access lunchAble to access break timeAble to access assemblyAble to attend school tripsNot ApplicableWould this pupil manage provision with other pupils? *Would this pupil manage provision with other pupils?YesNoNot ApplicablePreviousNextKey Contact Name *Phone *Email *Key Contact Role *Key Contact RoleParentCarerTeacherNot ApplicablePreviousNextSchool CP Officer Name *School CP Officer Phone Number *School CP Officer Email *PreviousNextAny other information which you think may help your applicationFile Upload Click or drag a file to this area to upload. Submit
