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Referral Form

During your time at the centre, you may be introduced to our members of staff who will support you throughout your time.

For the staff to support all your learning needs, please complete the questions below. This valuable information, unique to you, will allow all relevant staff members to understand you and your learning needs better.

If you have any questions or need a hand completing the form, we’re always happy to help. You can get in touch with us at referrals@hitchcoxgroup.co.uk

This information will be stored securely and processed in accordance with the General Data Protection Regulation (GDPR).

Student Name

Learner Details 

Emergency Contact Details
Does this contact have parental responsibility?

Referral Details
Please confirm that the school have carried out identification checks on the referred young person*
Programme you are looking for: (please choose any or all)
Parental contact?
Has funding been agreed prior to referral form being completed? (Please note We are only able to confirm start date/hold a place once you have confirmed funding has been agreed.)

Needs & Risks
Does the young person have an EHCP?
Has the young person been looked after / been a child we care for?
Is the young person currently, or have they previously been, on a child protection register?
Is the young person subject to TAF/CIN meetings?
Risk of absconding:
Risk of climbing to an unsafe height:
Risk of violence

Please attach the following


 No file chosen No file chosen No file chosen No file chosen No file chosen

SIGNATURE & CONFIRMATION

I confirm that I have read and understood Orchard Therapeutic Farm’s Terms and Conditions for Placements and wish to proceed with the referral process on behalf of the commissioning organisation.*
I confirm that I am authorised to make this referral and acknowledge that any placement is subject to Orchard Therapeutic Farm’s Terms and Conditions:*

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