1St Floor,Kingsway House, West Precinct

SEN and Engagement Team

1st Floor,Kingsway House, West Precinct

Billingham TS23 2NX

Email:

Tel: 01642 527110

DATE OF REFERRAL Click to Enter

PERSONAL/SCHOOL DETAILS
Name of Pupil: Insert
Date of Birth: Insert
Gender: M ☐ F ☐ Ethnicity Select
Home Language Click here to enter text
Interpreter, Signer Required (School to Arrange) Yes ☐ No ☐
Address Line 1: Address Line 1
Address Line 2: Address Line 2
Postcode: Post Code
If pupil is LAC, do not enter address of Foster Carer
LAC ☐ Home Authority if LAC Click here to enter text
If yes under which order? Sect 20 ☐Sect 31 ☐ Sect 38 ☐ / School: Insert Year: Select
Name of Head Teacher: Insert
Name of SENCo: Insert
SEN Status: Please Select
Pupil Premium ☐ GRT ☐ VEMT ☐
Young Carer ☐ CP/CIN ☐ D/V ☐
CYP in Custody ☐ Refugee/Asylum Seeker ☐
At Risk of Permanent Exclusion ☐
Unable to attend (Anxious/Medical Reasons) ☐
Other (please specify) Click here to enter text
Early Help Assessment has been undertaken ☐
(If yes, please include with referral)
Please state any Equality and Disability considerations we need to be aware of Click here to enter text.
PARENTS/CARERS/SOCIALWORKER (if applicable) DETAILS
Parental Responsibility ☐
Title: Choose
Surname: Insert
Forename: Insert
Address: (If different from above)
Address Line 1: Insert
Address Line 2: Insert
Telephone No: Insert / Parental Responsibility ☐
Title: Choose
Surname: Insert
Forename: Insert
Address: (If different from above)
Address Line 1: Insert
Address Line 2: Insert
Telephone No: Insert
SAFEGUARDING STATEMENT
All members of the SEN and Engagement Team share a responsibility for safeguarding and promoting welfare of children and young people and have a duty to follow the procedures approved by the Local Safeguarding Children Board and take appropriate action if they have concerns about a child’s welfare. Please find link to Tees Local Safeguarding Children’s Board’s Procedures ()
PERMISSION FOR REFERRAL
As the person(s) with parental responsibility for the above named child/young person I/we agree to the involvement of the Educational Psychology Service. I/we give permission for the Educational Psychology Service to:

contact any other agencies that have been, or will be involved in the future
share information and discuss action plans in the best interest of the above named child/young person with colleagues in the SEN and Engagement Team and other professionals

I/we understand this permission is valid for 12 months from the date below and whilst the child/young person is in the current setting. I understand the EP may work with my child or discuss my child with staff on more than one occasion during the period of consent. I/we understand I/we can withdraw my/our permission at any time in writing to the EPS.
I/we understand involvement will automatically cease and the child/young person’s file will close one year from the date below, unless otherwise requested.
I/we confirm I/we have had sight of the completed referral form.
I/we understand the information on this form and any information obtained as a result of Educational Psychology Service involvement will be stored in a written and electronic form by the Educational Psychology Service in accordance with the Data Protection Act 1998.
If signed parental permission is not given by at least one parent, the referral form will be returned to the person making the request. The EPS must receive the original signed consent.
For Children Looked After, the Social Worker MUST have signed the form.
Referrer Name Select…………………………….… Signature: …………………………………. Date: ……………………
Parent/Carer Name Select………………………………. Signature: ………………………………….. Date: ……………………
Parent/Carer Name Select ……………………………… Signature: ………………………………….. Date: ……………………
Social Worker Name Select ……………………………… Signature: …………………………………. Date: ……………………
REASON FOR REFERRALplease indicate primary/secondary need
Communication and Interaction ☐ P/S Social, Emotional and Mental Health Difficulties ☐ P/S
Cognition and Learning ☐ P/S Sensory and/or Physical ☐ P/S
EVIDENCE TO SUPPORT REFERRAL
Please attach any relevant reports/diagnostic letters (with parental consent) and current provision map.
What have you already done?
Risk and Resilience factors already identified?
Click here to enter text
DESIRED OUTCOMES FROM INVOLVEMENT OF EDUCATIONAL PSYCHOLOGY SERVICE
QUESTION(S) YOU WOULD LIKE EDUCATIONAL PSYCHOLOGIST TO ANSWER
The EPS will work with school primarily through consultation. It will be helpful to have an indication of what school are hoping to gain from EP involvement e.g.
Consideration/assessment of barriers to learning and how to overcome them☐
Consideration/assessment of communication difficulties or social, communication and interaction difficulties ☐
Consideration/assessment of social, emotional and mental health needs☐
Consideration/assessment of sensory and or physical needs☐
Specific intervention ☐
Whole school issue☐
Training☐
Other ☐ Click here to enter text
OTHER AGENCIES/PROFESSIONALS INVOLVED
AGENCY/PROFESSIONAL
(fields marked with * are mandatory) / NAME/CONTACT DETAILS
CAMHS
Speech & Language Therapy
Paediatrics
Medical Professional
Social Care
Inclusion Team
Private EP
*GP
*Attendance & Exclusion
(Include Attendance Certificate)
PLEASE RETURN THIS FORM TO THE ENGAGEMENT AND LEARNING TEAM – CONTACT DETAILS AT TOP OF FORM
Office Use Only
Details on ONE Date ……………………….. Initials …..
RAISE Check Date ……………………….. Initials …..

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