Make a Referral | P.L.O.T. CIC

Making a Referral

Accredited alternative therapeutic provision

If you would like to make a referral to P.L.O.T. Community Interest Company, please complete the referral form below and press ‘Submit’. Alternatively, if you would prefer to complete a paper copy of our referral form, you can download this at the bottom of the page.

Please complete the form as accurately and completely as possible, as this will support us in starting the placement in a swift manner.

Date referral made*

First name of child*

Surname of child*

Does the child have an EHCP? If yes, please forward a copy*

DOB*

Age*

Is the child a looked after child?*

Is the child adopted?*

How many days required?*

Parent/Carer Full Name*

Parent/Carer Phone Number*

Parent/Carer Address*

Referrer Full Name*

Referrer Email*

Referrer Address*

Is the Child On Roll at a School/Setting (please include details)*

Does the child interact with other children safely?*

Does the child follow instructions from adults?*

Does the child have violent outbursts or damage equipment?*

Does the child swear at staff?*

Does the child have violent outbursts towards other children and or adults?*

Does the child show empathy towards others?*

Can the child talk about feelings when upset?*

Can the child work alongside other children in the classroom?*

Does the child display anxious behaviour?*

Reason for referring*

Hoped for outcomes*

Weeks required*

Preferred start date*

Review date/End date*

Send invoices to: (Email address)*

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