adult learning and skills service

CONFIDENTIAL
Additional Support Referral Form
Many learners who need additional support because of a language, literacy or
numeracy need, learning difficulty or disability can be helped by the lecturer within
the class. Please use this form to refer any learner you believe would benefit from
any additional support. You should discuss this referral with the learner concerned
and inform them that a member of staff will contact them to arrange a confidential
interview. A member of staff will assess the learner's support needs, make
arrangements for support to be put in place and confirm the support to be provided.
The completed form should be handed in to Reception or emailed to
sean.buckley@lbhf.gov.uk .
If you would like to discuss a possible referral, or get advice about how best to work
with a learner with any of these needs, please contact the relevant member of staff.
Learner Name Enrolment Number .
Course Title

Course Code ....

Please tick reason support needed and give a brief description of support needs
[ ] Spoken English

[ ] Literacy

[ ] Numeracy

[ ] Physical disability

[ ] Hearing impairment

[ ] Learning difficulty
[ ] Visual Impairment

[ ] Other support needs (please specify)

Recommended Form of Support
[ ]
[ ]
[ ]

Support in class
Additional support out of class
IAG interview

Details of Referral
If you are recommending the learner needs out of class support please give the SMART
learning aim that you want the learner to achieve
.......
If you are referring to an IAG interview please give any relevant details on what the learners
enquiry is regarding ...
.......
Other relevant information/comments:

Signed (Lecturer) .. Date

Note to Reception Staff:
Please fax or email this form to Lee Brown immediately and send the original to Sean
Buckley via the internal post in a sealed envelope marked CONFIDENTIAL.

CSD/ALSS/SB/REFERRAL FORM JUNE 2011/YSP/21.06.11