Elective Home Education Notification / Enquiry Form

Practitioners can use this form to inform Cognus of a child/ren that they are aware of, or that they believe is receiving elective home education.

Date
MM slash DD slash YYYY
Child 1 Name*
First Last
Child 1 Date of Birth*
MM slash DD slash YYYY
Gender (Child 1)*
- Female
- Male
- Prefer not to say
Child 2 Name (ignore if not applicable)
First Last
Child 2 Date of Birth
MM slash DD slash YYYY
Gender (Child 2)
- Female
- Male
- Prefer not to say
Child 3 Name (ignore if not applicable)
First Last
Child 3 Date of Birth
MM slash DD slash YYYY
Gender (Child 3)
- Female
- Male
- Prefer not to say
Child/ren's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent / Carer 1 Full Name
First Last
Parent / Carer 1 Relationship to child/ren
Parent / Carer 1 address (if different to child/ren)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent / Carer 1 Email address
Parent / Carer 1 Mobile Telephone Number
Parent / Carer 1 Home Telephone Number
Parent / Carer 1 Work Telephone Number
Parent / Carer 2 Full Name
First Last
Parent / Carer 2 Relationship to child/ren
Parent / Carer 2 address (if different to child/ren)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent / Carer 2 Email address
Parent / Carer 2 Mobile Telephone Number
Parent / Carer 2 Home Telephone Number
Parent / Carer 2 Work Telephone Number
Referrer's Full Name*
First Last
Referrer's Organisation*
Referrer's Job Title*
Referrer's Email Address
Referrer's Mobile Telephone Number
Referrer's Work Telephone Number
Reason for engagement with family
Status (if known)
- Child Protection
- Child in Need
- Early Help
- Other
If other, please enter details of status
Reason for Contact
- Identified as EHE
- Concern EHE provision
Description of contact (if required)