REFERRAL FROM MAINSTREAM PRE-SCHOOL SETTINGS TO

BROMLEY SPECIALIST EARLY YEARS EDUCATION SERVICES

Referrer to complete form andsend to: Data & Panels Manager, PSS&D Service, Phoenix CRC, 40 Masons Hill, Bromley BR2 9JG,

Tel: 020 8315 4718/ 020 8315 4752 Fax: 020 8466 8855 E-mail:

1.Child’s details (Please PRINT details in CAPITALS)
Child’s Forename:
(Please print) / Surname:
(Please print) / ONE No:
(Office use)
D.o.B: / Gender:MaleFemale / Siblings:
Address: / Full Names of parents / carers (Mr, Mrs, Miss, Ms):
Health lead practitioner (if known)
Family’s first language:
Family’s ethnicity:
Is help required in interpreting and/or
reading any information?Yes No
Postcode:
Home Tel: / Name of Early Years Setting currently attending:
Date started:No of Sessions/Days:
Work/Mobile Tel:
Email address: / Likely mainstream school and start date:
2.Referral
Please indicate with a tick in the box(es) your reason(s) for referral, and say briefly here what outcome you are expecting for this child from specialist early years education services.
Initial assessment by the Specialist Early Years Education Services
Initial assessment by Sensory Support (Vision) (Hearing)
Note: If your concern is focused on hearing or vision needs then please do not complete this form until you have telephoned the Bromley Sensory Support Service - 01689 889 850 (Vision) / 01689 889 856 (Hearing)
Complex health needs only - training and support in pre-school or preparation for transition to school
Educational Psychology Service
Note: Parents/professionals can apply directly to Petts Wood SN Playgroup and do not need to be referred through this form
Notes: (Office use only)
3. Nature of child’s needs and diagnosis (if any)
4. Parents’/Carers’ Views (to be completed by parents/carers)
5. Progress and Assessments
When completing the appropriate boxes below, please be specific noting the band the child is currently working within i.e. 22-36 months. Please attach a printout of Early Years Pupil Report as it would be helpful to have information tracking progress over time.
Child’s age in months:
Early Years Foundation Stage Curriculum
Area of development / Personal, social and
emotional development / Communication and language / Physical development
Making relationships / Self-confidence and self-awareness / Managing feelings and behaviour / Listening and attention / Understanding / Speaking / Moving and handling / Health and
self-care
Emerging
Working within
Secure
6. Current Provision
When approximately did the setting first discuss concerns with parents/carers?
When were additional strategies first introduced?
What strategies have been used and what has been their impact?
What is the child’s ability to access the Early Years Foundation Stage?
How does the child interact with peers?
How does the child interact with adults?
Physical / health / personal care needs
PLEASE ATTACH IEPs or EQUIVALENT PAPERWORK THAT PROVIDES EVIDENCE OF YOUR INTERVENTIONS
7. Activities and outcomes from professionals and servicesinvolved with the family
Agency/Service
/ Report attached (please tick) or date referral made / Professional contacts & tel nos
Education
Other Pre-school/early years setting
Petts Wood Playgroup
Sensory Support
Health
Children’s Resource Feeding Team (S&LT)
Integrated Children’s Community Nursing Team
C.C.D.S. (Complex Communication Diagnostic Service)
Consultant - Specialist
C.A.M.H.S. (Child Adolescent Mental Health Service)
G.P./Doctor
Dietician
Health Visitor
Paediatrician - Community
Paediatrician - Hospital
Physiotherapist
Occupational Therapist
Speech & Language Therapist
Care
Social Worker (Disabled Children’s SW and SB Team)
Social Worker (Other)
Others
Voluntary Services and others
8.Parents’/Carers’ Consent
Parental signature must be obtained before this referral can be actioned.
(a)Is this child a ‘Child Looked After’? (CLA, e.g. foster care) / Yes No
(b)Is this child subject to a Child Protection Plan? / Yes No
(c)Is this childsubject to Child in Need Plan? / Yes No
(d)Does this child have a CAF? / Yes No
(e)Please sign to confirm your agreement to the referral and give permission for the services to share information confidentially
with appropriate education, health and social care professionals in order to support your child.
Parent’s/Carer’s Signature: ………………………………………………………………………….. Date:…………….………
Parent’s/Carer’s NAME (PLEASE PRINT)………………………………………………………………………………………..
Relationship to child (PLEASE PRINT)………………………………………………………………………………………..
The information on pupils with SEN is provided/gathered in accordance with the Data Protection Protocol agreed between Bromley LA and the Admissions Authorities within the Borough. You may receive services from a number of people. So that we can all work together for your child’s benefit, we may need to share some information. We only ever use or pass on information if professionals have a genuine need for it. Law strictly controls the sharing of some types of very sensitive personal information. Anyone who receives information from us is also under a legal duty to keep it confidential. All data are stored on a secure database. Relevant information shared will remain confidential through observance of best practice set out in HM Government’s information sharing guidance (2008) and the Data Protection Act (1998)
9.Referrer’s Details: (PLEASE COMPLETE IN FULL)
Referred by:Position:
Tel No:Email:
Contact Address
Referrer’s Signature: ………………………………………………………………………………….. Date:…………….………
N.B. If there are any specific domestic circumstances that should be made known to Bromley Specialist Early Years Education Services, then please let us know.

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