Catholic Education Office

Diocese of Wollongong

MSPEC INTERVENTION REFERRAL

(Form Vers.15, 16 February, 2015)

Date of MSPEC Intervention Referral Submission to CEO: / Triple click here to enter text
Student Name: / Triple click here to enter text / Date of Birth: / Triple click here to enter text / Year/Grade: / Triple click here to enter text / Gender: / Triple click here to enter text
Teacher: / Click here to enter text. / School: / Triple click here to enter text / If other specify: Click here to enter text
Case Manager: Click here to enter text.
Is the school receiving additional funding for this student? / SWD Indigenous ESL/NA Other (Give details)
Has the Parent/Carer been notified of this referral? / Yes No
PRINCIPAL’S AUTHORISATION
It may be necessary for CEO personnel to have some direct involvement in order to collaboratively determine the most appropriate intervention strategies. This may include observing the student in-situ (eg. playground, classroom, etc).
Has the Principal authorised this request? / Yes No
URGENT response required. (Student is deemed to be at significant risk of harm to self or others and/or student is at risk of suspension)
SECTION A – RELEVANT AREAS
Indicate ALL RELEVANT AREAS for this referral:
Behaviour Indigenous Problem Sexual Behaviour Work Health & Safety
Child Protection Literacy Psychometric Assessment Pastoral
ESL Student with Disability Safety, Welfare & Wellbeing Gifted
New Arrival Sensory/Hearing/Vision Mental Health
Formal Risk Assessment Numeracy Staff/Leader Capacity
SECTION B – KEY EDUCATION DETAILS
Most recent NAPLAN Bands
Numeracy: Triple click here to enter BANDS Reading: Triple click here to enter BANDS Writing: Triple click here to enter BANDS
Spelling: Triple click here to enter BANDS Punctuation & Grammar: Triple click here to enter BANDS
Syllabus outcomes student currently demonstrating:
Mathematics: Stage Triple click here to enter STAGE English: Stage Triple click here to enter STAGE
Regular Syllabus outcomes all courses
Life Skills outcomes all courses
Combination of Life Skills & Regular Syllabus outcomes
Existing Diagnosis: Specify: Triple click here to enter SPECIFY
Is there case management for this student? Yes (include a copy of the report) No
Participation in, or currently, in Reading Recovery? Yes(include a copy of the report) No
Has student been referred off Reading Recovery? Yes(include a copy of the report) No
SECTION C – OTHER KEY INFORMATION, HEALTH PROFESSIONALS INVOLVED, REPORTS AND PLANS
Please note, or request (from Parents(s)/Carer wherever possible) additional health professional information or other agency reports, prior to submitting this CEO referral.
Attach any documentation that is not on file with CEO.
PROFESSIONALS INVOLVED
Paediatrician: Triple click here to enter DATE Audiogram: Triple click here to enter DATE
Psychiatrist: Triple click here to enter DATE Speech Pathologist: Triple click here to enter DATE
CEO Psychologist: Triple click here to enter DATE Other Health Professional: Triple click here to enter DATE
Psychologist: Triple click here to enter DATE Agency Report: Triple click here to enter DATE
Vision Assessment: Triple click here to enter DATE CatholicCare Counsellor: Ongoing Completed
Have the strategies/recommendations from the health professional or other agency reports been implemented?
Yes No Partially N/A
Do you have a signed Release of Information Form for professional involved if this information is not readily available?
Yes No
PLANS IN PLACE – Please attach copies of all plans
Personal Plan (PP) Behaviour Support Plan Health Plan
Mental Health Care Plan Risk Management Plan Safety Plan
Other, Please specify, Enter text here
OTHER
History of: Middle Ear Infections Common Colds Grommets Other
SECTION D – Indicate the Main Reason/s for Seeking Referral
Learning Support
Attach MSPEC Committee Notes and/or relevant documentation
Curriculum Access Communication Mobility Safety Personal Care
Social/Emotional Classroom Observation Psychometric Assessment Gifted Education
Acceleration SWD (Please state category of disability): Enter text here
Psychometric Assessment Application (Please tick all Relevant Boxes)
Attach all relevant MSPEC documentation including notes to support the psychometric assessment request.
1. State the number of years fluent English has been spoken by the student. Enter text here years
2. This request is from:
School Concern Paediatrician (Attach letter) Health Professional (Attach letter)
3. Do you suspect any underlying conditions (eg. Anxiety, Autism, Intellectual Disability, Oppositional Defiance Disorder (ODD), Attention Deficit Hyperactivity Disorder (ADHD) or a Specific Learning Disorder) Yes No
If yes, please include/attach a brief description of your concerns and the student’s behaviours and Individual Plans
Triple click here to enter text
4. Has the student had a psychometric assessment within the last 3 years? Yes No
Child Protection
Attach Forms and all relevant documentation
Concern for child(ren):
This student Other student/s Sibling/s Other child(ren).Enter text here
Forms completed
Incident Report MRG Decision Report (Mandatory Reporter Guide) Risk Assessment Other. Enter text here
Work Health & Safety
Attach Forms and all relevant documentation
Safety of person/s:
Employee Student Volunteer Contractor Member of Religious Order
Forms completed
Register of Injuries Student Accident Report Accident/Incident Investigation Risk Assessment
Other.Enter text here
Staff/Leader Capacity
Attach Forms and all relevant documentation
Staff member(s):
Teacher SSO Middle Leader Principal Other. Enter text here
Complete for all referrals
Description of reason for referral:
Triple click here to enter text
Successful strategies:
Triple click here to enter text
Less successful strategies:
Triple click here to enter text
What do you hope will be achieved as a result of this referral:
Triple click here to enter text
Please attach all relevant MSPEC documentation. Please note this documentation should provide information regarding the intervention strategies that have been implemented at the school level.
FORWARD/EMAIL completed form and all relevant information to MSPEC ()
If posting additional information to CEO, send to:
Attention: Confidential - MSPEC
Catholic Education Office
Locked Mail Bag 8802
WOLLONGONG NSW 2500
CEO OFFICE USE ONLY
SI-Primary / SI-Secondary / SI-SS / WH&S / CP
Date Received: Click here to enter a date.
CEO Team Leader: Click here to enter text.
/ CEO Wollongong/MSPEC/Intervention Referral Form/V15/10022015 / 1