Referral Form /
Brian Jackson College Independent Inclusion for KS4
Initial Referral Form
SCHOOL DETAILSSchool
Key School Contact
Contact number
STUDENT DETAILS
Surname: / First Names:
Previous Names (AKA): / Unique Student No:
Address: / Male Female
Date of Birth:
Year Group:
Not on School Roll (CME)
Ethnic Code: Nationality: Religion:
Childs first language or preferred means of communication: / Interpreter/signer required for child/young person:
YES NO
Immigration status: Asylum Seeking Refugee Status Exceptional Leave to Remain
Who is the student living with?
Single parent Parents Grandparents Friends Looked after child Other (please state)
STUDENTS BACKGROUND
Young Offender Learner with Disability Excluded Poor Attendee
Traveller At risk of exclusion
PARENT/CARER INFORMATION
Mr/Mrs/Miss/other: / Full Name:
Relationship to Child/young person:
Address:
CONTACT DETAILS/TELEPHONE NUMBER:
1st Language: Interpreter required: YES NO
Does this person have parental responsibility: YES NO (if NO – complete below)
Name of person with Parental Responsibility and contact details:
Other significant members of the family:
HEALTH
Is the student taking any medication or have any allergies? / YES NO
Does the learner have any health/support needs, including mental, emotional and physical? / YES NO
Is the learner currently working with any other agencies to access support with any health issues? / YES NO
SPECIAL NEEDS INFORMATION
Does the learner have any disabilities? / YES NO
Does the learner have any special needs? / YES NO
If yes, at what stage are they? (please tick)
School Action School Action + Statement/EHCP
Is there an ILP/PEP in place? / YES NO
Additional information attached (if required) / YES NO
SAFEGUARDING
Is the learner currently working with any other agencies to access support with any safeguarding
Issues? / YES NO
Does the learner have any caring responsibilities? / YES NO
Does the learner feel safe from harm? / YES NO
AGENCY INVOLVEMENT: please provide contact details including lead professional, actions following agency
involvement and outcomes
Education psychologist
Actions: / Contact:
Outcomes:
Attendance and Pupil Support Service
Actions: / Contact:
Outcomes:
Family Support and Child protection Services
(Social Worker)
Actions: / Contact:
Outcomes:
Mental Health Services CAMHS CHEWS
Actions: / Contact:
Outcomes:
Health
Actions: / Contact:
Outcomes:
YOT
Actions: / Contact:
Outcomes:
Other please specify:
Actions: / Contact:
Outcomes:
GENERAL LEARNER INFORMATION
Please use this box to include any additional information regarding anything that could prohibit the young person from achieving/engaging with
Learning? (eg travel, caring, responsibilities, previous negative experiences, relationship to parents etc.)
REASON FOR REFERRAL: (Nature of Concern)
ACTIONS TAKEN: (School Interventions) / OUTCOMES: (Following School Interventions)
DAY 6 – to be completed for all permanent exclusions.
Date of permanent exclusion:
Date notified LA: / Day 6 Provision start date:
REASONS FOR EXCLUSION: Please provide FULL DETAILS of the current exclusion, i.e. what behaviour/incidents lead to this exclusion?
If a child/young person is a health and safety risk please provide contact details for a person in school who can contribute to a risk assessment.
Is a Risk Assessment required? YES NO
Parent/Carer & Childs Views
Within this section schools should summarise the views of the parent/carers, (through consultation), and seek to establish the views and
concerns of the child.
CHILDS STRENGTHS/INTERESTS:
VIEWS OF PARENTS/CARERS:
Please indicate the views of parents/carers: / VIEWS OF THE CHILD:
Please indicate the views of the child:
CHILD/YOUNG PERSON INFORMATION (PLEASE COMPLETE IN FULL)
CURRENT ATTENDANCE (%) ATTENDANCE LAST ACADEMIC YEAR (%)
Please provide a printed copy of (SIMS) data for the child’s last academic year:
Data provided YES NO
Reading Age:
Test Date: / COGNITIVE ABILITIES TEST (CAT)
V N NV
PLEASE PROVIDE ANY INFORMATION YOU HAVE AROUND ATTAINMENT & PROGRESS
ENGLISH: MATHS: SCIENCE: ICT:
Please indicate if child is making expected progress: YES NO
IS THIS CHILD ENTITLED TO FREE SCHOOL MEALS: YES NO
DOES THIS CHILD ATTRACT PUPIL PREMIUM FUNDING: YES NO
INTERVENTIONS
USING PUPIL PREMIUM FUNDING:
LOOKED AFTER CHILDREN: (Children & young people in care)
Is this CHILD/YOUNG PERSON Looked after? YES NO
PEP DATE:
Has the school applied for additional LAC funding (pupil premium plus) / YES NO
DOES THE LEARNER HAVE:
A preferred learning style? / YES NO
Auditory Kinaesthetic visual
A history of poor school attendance? / YES NO
A noted decrease in school attendance? / YES NO
Limited social skills? / YES NO
Low self esteem and self confidence? / YES NO
A lack of commitment to learning? / YES NO
Low aspirations, or is there evidence of limited educational progress, but
Not necessarily lacking in ability? / YES NO
Disaffection from formal school for academic or social reasons? / YES NO
External factors limiting achievement? / YES NO
Complex support needs eg ADHD, Aspergers?
Are they at risk? / YES NO
YES NO
Any other issues? (Please give details in the space below)
To be completed for all referrals to Brian Jackson College KS4 Inclusion
Exam Entries/Courses Studied
SUBJECT / BOARD / CURRENT STATUS (i.e. work completed and
Modules taken, exam entries) / PREDICTED
GRADES
Additional Information:
What does the young person do well and enjoy?
What are the young person’s ambitions/hopes for the future?
Are there any reasons to suggest that the young person might
Exploit others (bullying, intimidation, offending and so on)? / YES
NO / Please specify if YES:
Are there any reasons to suggest that the young person is “a victim”
And might be exploited? / YES
NO / Please specify if YES:
Are there other young people who s/he should not mix with? / YES
NO / Please specify if YES:
Is there evidence of drug, alcohol or substance misuse? / YES
NO / Please specify if YES:
Should reintegration seem to be appropriate in the future, will
You be prepared to readmit the young person subject to
Negotiation? / YES
NO / Comments:
Is the young person currently enrolled in any other alternative
Provision/engagement programme/NEXUS? / YES
NO / Please specify if YES:
Could the young person continue with this activity whist attending
Brian Jackson College? / YES
NO / Comments:
Please complete consent form
PARENTS/CARERS CONSENT TO REFERRAL AND INFORMATION SHARING WITH OTHER RELEVANT AGENCIES
This section of the form should be completed with parents/carers.
Attendance at most of the alternative resources involves young person’s travelling to and from by public transport. Are parents/carers prepared to allow this? Costs are usually covered.
Is the young person capable of travelling independently? YES NO
Parents/carers declaration:
I agree that this referral may be made and that the information given on this form, as well as any relevant information from other sources, may
be made available to Brian Jackson College. All of the information in this referral may also be shared with other agencies. Throughout the
placement process and during the placement, additional help for my child may be provided by the school in partnership with Brian Jackson
College.
Signed:
Name (printed) Date:
Has parents/carers signature been obtained and dated? YES NO
School to retain a signed copy.
HEAD TEACHERS CONSENT:
IF ON A SCHOOL ROLL – the Head Teachers agreement to the referral must be obtained.
HEAD TEACHERS CONSENT: I agree that this referral may be made and that the information given on this form, as well as any other relevant
Information from other sources may be made available to Brian Jackson College.
All of the information in this referral may be shared with other agencies involved. I agree to the funding arrangements.
Signed (or electronic signature)
Name (printed) DATE:
Has the Head Teachers signature been obtained and dated? YES NO
Date received by Brian Jackson College:
Initial Action to be taken:
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