Independent Travel Training Team

Liverpool City Council

Cunard Buildings

Water Street

Liverpool L3 1AH

Tel: 0151 233 5954/5974

email:

Referral form

Eligibility criteria – To access this training all students must be 18 or under by September and be eligible for SEN home to school transport.

It is essential for the Travel Training Team to have all relevant background information in order to assess the level of training and support required. All information supplied is strictly confidential.

Trainee name
Date of birth
Age
Gender
Home address
Postcode
Parent / Carer name
Home phone number
Mobile number

Referrer (Teacher /parents/Carers.)

Name of referrer
Location of referrer
Contact number
Date

Journey Details

From
To
Return journey required
Start and finish times

About the learner

Have they received Travel Training before?
Do they receive transport through Local Authority Transport Team? / Yes/No (If yes please state if this is by taxi or bus?)
If transport is shared please list full names of whom this is shared with:
Do they have a travel pass?
Additional information: Motivation to make the journey / Confidence / Personality traits

Personal risk assessment

Does this person: / Yes / No / Not known
Have any medical issues?
Have any physical or sensory disabilities?
Have any allergies or phobias?
Have any issues relating to behaviour?
Have an increased dependency on support?
Can this person… / Yes / No / Not known
Recognise the dangers of crossing the road?
Use a light controlled and/or pedestrian crossing?
Cross safely without using a recognised crossing?
Learn to remember routes and directions?
Read a bus number / destination?
Request help from an appropriate source?
Deal appropriately with strangers?
Maintain their own personal safety?
Relatives emergency contact details: / Name:
Address:
Phone No:
Other information - Please comment on anything relevant that has not been included on this form already:

Completed forms to be returned to or Independent Travel Training Team, Liverpool City Council, Cunard Buildings, Water Street, Liverpool L3 1AH.

OFFICE USE ONLY

Date received / Trainer assigned / Bus pass
Home visit / Start date / End date

2016 v 1