Connex Tutors Pupil Referral Form – Pupil Support Mentors

Please complete the details below in as much detail as possible to help us prepare your programme and assign appropriate candidates. 

Pupil Name(Required)
DD slash MM slash YYYY
Does the pupil have an EHCP?
DD slash MM slash YYYY
DD slash MM slash YYYY
Max. file size: 16 MB.
Has the pupil/young person been diagnosed with any conditions which could impact their learning?
Does the young person have any medical conditions we should be aware of?

Intervention Details

Targets or areas of focus: (Please include areas you would like us to work on or how we can support the pupil. E.g. improving confidence, building relationships, in class support with regulating behaviour, support with transition times around school.)
T1
T2
T3
Does the pupil require academic intervention as part of this programme?
Please give details of curriculum areas and learning outcomes you wish to target.
T1
T2
T3
Does the pupil have any upcoming exams in the next 12 months that you would like us to support them with?
What is your preferred frequency?

Intervention Lead Contact Details

Contact Name(Required)
Please complete the below section for any pupils working outside of mainstream education.
Is the pupil currently on roll with an educational institution?
I confirm that I have the relevant authority to commission Connex Education to work with the named pupil.

Parent/Carer Contact Details

Name of parent/carer

Finance

Permissions(Required)
This field is for validation purposes and should be left unchanged.

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