Pathways Referral form

Name

DOB

UPN

Has the young person got an Education Health and Care Plan (EHCP)?
OR
Is the young person currently going through EHC needs assessment?
OR
Has the EHC needsassessment request been heard at MAP within the last 6 school weeks

Where appropriate, the below documents can be sent as separate attachments with the referral form:

  • Behaviour summary
/
  • Cluster support

  • Early help plan
/
  • Risk assessment

  • Positive handling plan
/
  • Individual behaviour plan

  • PEP (CLA)
/
  • Summary of report outcomes

PLEASE NOTE, NO OTHER ATTACHMENTS WILL BE ACCEPTED ALONGSIDE THE REFERRAL UNLESS SPECIFIC EXCEPTION IS REQUIRED AND AGREED BY PANEL CHAIR
(PLEASE EXPLAIN ANY EXCEPTIONS WHEN SUBMITTING DOCUMENTATION)

Dates of meetings

Meetings will take place every Tuesday 08:00-10:00am

Autumn Term / Spring Term / Summer Term
13th September
20th September
27th September
4th October
11th October
18th October
Half term??
1st November
8th November
15th November
22nd November
29th November
6th December
13th December
20th December

Referral Checklist(to be completed by referrer)

Yes / No
PX referral / Date of PX
Exceptional case referral
EHC Needs Assessment referral submitted / Date on confirmation letter
SENCO signature
AIP quality assurance

Decision(For panel use only)

Yes / No
Advice to school/academy
Referral to Wellspring
Referral to alternative provision ( PX)
SEMH Pathway Panel Referral / Date of referral:
Surname: / D.O.B: / UPN:
Forename: / Year Group:
School: / Gender:Male/FemaleMaleFemale Ethnicity:
Disadvantaged: Y/NYesNo FSM: Y/NYesNo
(eligible for pupil premium funding)
Attendance %: Last Year’s Attendance %:
School Contact:
Designation:
Tel no:
Email: / Social Work Contact:
Designation:
Tel no:
Email: / Parent/Carer
Name/s:
Address:
Tel no:
Emergency contact 1:
Name:
Address:
Tel no: / Emergency contact 1:
Name:
Address:
Tel no:
Give a synopsis of the pupils history and of specific incident(s)/issues leading to referral (Please attach a behaviour summary)
No. of fixed term exclusions in the last 12 months: / No. of fixed term exclusion days: / No of internal exclusions (isolations):
Schooling History (include all Key stages, any Alternative provisions & managed moves) / Dates attended:DD/MM/YY - DD/MM/YY
AIP
Area / Name of AIP Lead:
AIP Lead Signature (agreed to the referral):
Cluster
SEN Status / CLA (PEP **) / Y/NYesNo / Virtual School Consulted / Y/NYesNo
Cluster Support** / Y/NYesNo / Complex Needs Service / Y/NYesNo / Accommodated / Y/NYesNo
Safeguarding Concerns / Y/NYesNo / FFI Funding / Y/NYesNo / Care Order / Y/NYesNo
Early Help Plan ** / Y/NYesNo / Band / A B C D E F G / Supervision Order / Y/NYesNo
Early help assessment offered / Y/NYesNo / Number of Units / Residence Order / Y/NYesNo
Risk Assessment ** / Y/NYesNo / EP involvement / Y/NYesNo / Child Protection / Y/NYesNo
Positive Handling Plan ** / Y/NYesNo / Request for EHCP Assessment / Y/NYesNo / Child in Need Plan / Y/NYesNo
Individual Behaviour Plan ** / Y/NYesNo / Attendance support / Y/NYesNo / Counselling/CAMHs / Y/NYesNo
** please attach the documents with the referral
Describe the key behaviour issues: Please highlight - 1 is high, 4 is low. (Add more rows if needed) / Severity / Frequency / Duration
1/2/3/41234 / 1/2/3/41234 / 1/2/3/41234
1/2/3/41234 / 1/2/3/41234 / 1/2/3/41234
1/2/3/41234 / 1/2/3/41234 / 1/2/3/41234
1/2/3/41234 / 1/2/3/41234 / 1/2/3/41234
1/2/3/41234 / 1/2/3/41234 / 1/2/3/41234
Please outline the key wave 1 and wave 2 strategies tried
Strategies used 1 is very successful; 4 is unsuccessful. S = School E = External D = Duration(weeks) (Add more rows if needed) / SE / D / Success
1/2/3/41234
1/2/3/41234
1/2/3/41234
1/2/3/41234
1/2/3/41234
1/2/3/41234
1/2/3/41234
1/2/3/41234
What overall impact have these strategies had? / Please list behaviour triggers:
Are there any existing medical issues? / Y/NYesNo / Are there any child protection issues, or CSE concerns? / Y/NYesNo
Please give details / Please give details
Other agencies currently involved: / What is the role of the agency? / Lead person / Contact details
Parental Agreement obtained: Y/NYesNo / Student Agreement Obtained Y/NYesNo
Who from school will lead on re-inclusion and attend reviews?
Tel.
Email.
What wave 3 support are you requesting? Please tick
Support a managed Move
Guidance of next steps
Other AIP/ other Alternative provision/pathway
Response following a PX
Short initial assessment place at Springwell Leeds
Moved into Leeds following PX from another LA
Educational Outcomes- currently working at (Please outline all qualifications studied at KS4)
KS1 / Maths: / Reading: / Writing: / SPAG:
KS2 / Maths: / Reading: / Writing: / SPAG:
KS3 / Maths: / English: / Science: / Reading age:
KS4 / Current Grades / Target Grades
Maths
English
Science
Emotional literacy score: / SDQ: / Other:
Thoughts and Feelings of the Child/Young person:
Please outline any current and recent experiences that are contributing to the young person’s SEMH needs?
What help do you think the young person needs?
Strengths and Interests – what are the positive aspects of this student’s engagement?
What are they good at? What do they enjoy?
Provision Needs – cross any needs identified for future provision
Small groups / GCSE provision
Nurture provision / Vocational Qualifications
Specialist SEMH support
Additional Comments:
Parent/Carer views (if not a PX)
I have attended a review meeting of my child’s progress and agreed that my child can be presented to the SEMH panel to discuss their needs.
Further comments:
Parent/Carer signature/s / Date:
Child/Young Persons view
I agree that it would be helpful for me to make a new start at another school.
I will visit the new school/setting and will talk to the teachers about what I can do and what they can do to help me to do well.
I will listen to the teachers at the new school/setting about what they expect me to do and I agree to work hard to keep the school/setting rules.
Additional Comments:
Name of student / Signature

Wave Support SEMH Children & Young People

Please use the following to outline the support strategies and their affect to date

Wave 1- Universal Offer / Date initiated / Review Dates: / Did it work, how was progress measured?
Quality First Teaching Strategies
Positive transition at all Key Stages
Inclusive and positive behaviour policy in place
Classroom management plan in place
Positive meet and greet every lesson
Strategic seating plan
Consistent use of positive language
Demonstrate and praise positive behaviours
School and classroom rules displayed and consistently reinforced
Consistent use of rewards and sanctions
Consistent behaviour management strategies
Classroom arrangement (seating, lighting, sound etc)
Planning
Classroom organisation
The curriculum support and promotes emotional health
Appropriate curriculum
Differentiation and personalisation of learning
Episodes and transitions
Address the gaps in learning
Opportunities for self-assessment/reflection
Learning
Teaching styles adapted when necessary
Clear learning and behaviour targets
Ongoing monitoring, reviewing and evaluation of progress
Chunk work to enable pupil engagement
Clear purpose of learning
Problem Solving buddies
Promotion of independent learning
Regular communication with parents
Effective PSHCE program in place to develop resilience
Pupil support mechanisms in place (pupil voice)
Wave 2- Support outside the classroom
Use of timeout card
Low level reports i.e. Subject, Form Tutor
Use of TA/Learning mentor for 1:1 support
Parental engagement meetings
IEP/IBP/PSP/Passport etc. initiated
Regular home/school communication
Group work/1:1 work sessions in school to build understanding/skills in….
Internal resources implemented
Nurture Groups
SEAL/Social skills group
Home school liaison
Inclusion/learning support units
Access to specific emotional literacy programmes
Referral to the SENCO to identify deeper learning needs through assessment
In school tests for Dyslexia, Irlens, Lexia etc.
Peer Mentoring in place
Build Staff Capacity to manage SEMH CYP
Staff training
Wave 3- Targeted Support (Interventions that support skills, development and capacity in Wave 1 &2, but supported by further advice from appropriate professionals)
Early help assessment offered
Early help plan (multi-agency) initiated
Referral for cluster support
Counselling/Therapeutic Services
SENIT (Complex Needs Team) involvement
Educational Psychologist
Sought advice from the AIP
AIP offering outreach support
Referral to the school nursing team
Speech and Language Therapy
Applied for funding for inclusion
Involvement with Stars (Autism)
Managed move offered/implemented
Involvement with or referrals to CSWS
Youth Service
MindMate Spa
CAMHS assessment
Youth Offending Service
Please give brief details of any known convictions
Social Work Service
Attending or offered and alternative pathway to support their curriculum offer (college placement)
Attending an offsite Alternative Provision beyond 1 day per week
Voluntary Sector support
MST/Signpost
Any other Alternative Provision
(please specify)
Application for an Education Health Care Plan
Interventions that support skills development/ YP capacity as in Wave 2, but informed by further advice from appropriate professionals…..list

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Version: Draft (2) Pathway Panel Referral FormSep 2016