Norwich Community West

Request for Cluster SEND Support

Referral Form

This information will be kept confidential and only disclosed to members of Norwich Community West, except if there is a risk of harm.

When complete please email this form to

All other documents and supporting evidence can be posted to

Laura Myles, City Academy Norwich, 299 Bluebell Road, Norwich, NR4 7LP

Please see the checklist on page 7 for documents required to support the referral.

Pupil Information

Name(Full Legal)
Also Known As
DOB / UPN
Gender / Female / Male
First Language
Parent / Carer Name
Address
Post Code
Contact Number
School
Start Date at School
Expected Leaving Date
Current Year Group
Correct for chronological age / Yes / No
Has this pupil accessed an SRB? / Yes / No
If yes please give details
Eligible for Pupil Premium / Yes / No

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SEND Stage on Code of Practice

SEN Support / Statement of SEN / Education Health Care Plan
Health Care Plan

SEND Profile (Please indicate all relevant - P = Primary SENDS = all Secondary SEND

Communication and Interaction
(ASD, ODD, SLCN) / P
S / Cognition and Learning
(SpLD, MLD, SLD, PMLD) / P
S
Social, Emotional and Mental Health
(ADHD, ADD, Attachment Disorder, Mental Health) / P
S / Sensory and/or Physical
(HI, VI, MSI, PD) / P
S

Please comment on needs

Before a referral will be considered please ensure these have been accessed if appropriate(Please give dates when available)

Assessment / Date / Accessed / Comments
Advisory Teacher assessment
Educational Psychologist assessment
Eye test
GP / Hospital Referral
Hearing test
SENDCO assessment
Sensory Support assessment
Speech and Language assessment

Learning Baseline Information

Is the pupil Early Years Foundation Stage? / Yes
(Please provide EYFS Profile) / No

Current Attainment Levels (an Assessment Tracker printout is acceptable)

Attainment for / Previous Level / Date / Current Level / Date / Prediction Target
English - Reading
English - Writing
English - Listening (receptive)
English - Speaking
Maths - Shape, Space, Measures
Maths - Number
Maths - Using and Applying Maths
Science
ICT

Assessment Results (Please use standardised scores)

Assessment for / Assessment Used / Previous Result / Date / Current Result / Date / Prediction / Target
Reading Accuracy
Comprehension
Spelling
Number
British Picture Vocabulary Scale (Language)

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Strengths / Weaknesses

National Curriculum Levels

Previous Level / Date / Current Level / Date
Reading
Spelling
Writing

Out of School Support

Other agencies involved (Please list all involved with child and family)

Family Support Plan (FSP) / Yes / No
Section 17 / Yes / No
Section 47 / Yes / No
Looked After Child / Yes / No
Lead Professional / Social Worker Name
Contact Number

Referral Information

Main reason for referral

Behaviour / Language and Communication / Learning
Medical / Safety / Social, Emotional and Mental Health

Please give further detail regarding reason for referral

What interventions are currently in place and what has already been tried?

In place:
Already tried:

What would Cluster support be used for?

How would the Cluster support affect others?

What barriers are the school experiencing which means that the school cannot provide the support that this pupil requires?

What are the expected outcomes and what monitoring will be used?

Area / Outcome / Monitoring
Behaviour
Language and Communication
Learning
Medical
Safety
Social Emotional and Mental Health

What is the parent / carer view on the referral?

What is the child’s view on the referral?

What is the estimated cost? (Please include detailed budget if available)

Funding is for maximum of one academic year (three terms) - reapplication required after this. Any equipment purchased remains the property of Norwich Community West.

Please indicate which package of support you are requesting, (packages can have an impact on more than one child)

Low - £1k / Medium - £4k
High - £6k / Exceptional - £8k
Funding time frame(emergency funding termly only - packages will be pro-rata)
Could this resource be used across the School / Yes / No

Check List (if applicable please included supporting information and documents for all below)

SEN Support
Education Health Care Plan:
  • Document / Reviews

Statement of SEN:
  • Statement / Reviews

Health Care Plan
Advisory Teacher assessment
Educational Psychologist assessment
Eye test information
GP / Hospital Referral
Hearing test information
SENDCO Assessment
Sensory Support assessment
Speech and Language assessment
Individual Education Plan
Pastoral Support Plan
Behaviour Support Plan / Behavioural Reports
Interventions in place and tried
Detailed budget
Early Years Foundation Stage Profile
Assessment Tracker
Family Support Plan (FSP)
  • Initial Assessment / Delivery Plans

Norwich Community West

Request for Cluster SEND Support

Consent Form

This information will be kept confidential and only disclosed to members of Norwich Community West, except if there is a risk of harm.

Child’s Name
Child’s School
I confirm that I have discussed this referral with my child’s school and agree for information pertaining to my child’s personal information including Special Educational, Disabilities, Learning and Medical Needs being disclosed to members of Norwich Community West.
Parent / Carer Name
Parent / Carer Signature
Date
Please complete below if Referrer is not the Head Teacher.
Referrer Name
Referrer Signature
Date
I agree for the Request for Cluster SEND Support to be completed and agree to supply all information requested where applicable.
Head Teacher Name
Head Teacher Signature
Date
If the child is able to participate and it is appropriate for such please include the child’s consent below.
Child’s Signature (if appropriate)
Date

Please post the original completed consent form to

Laura Myles

City Academy Norwich, 299 Bluebell Road, Norwich, NR4 7LP

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