RBKC Learning Mentor Strand

Referral Form to Primary Learning Mentor

Removing barriers to learning

Pupil’s Name: / Year group / Class:
Person who is referring: / Today’s Date:

Reasons for Referral (see criteria over the page for barriers to learning)

1.

2.

3.

How long has the child been a concern?

What current or previous support strategies have been put in place?

What are the pupil’s strengths?

What changes do you want to see?

Criteria for Learning Mentor Support

Learning issues
Lacking motivation
Lacking confidence
Passive learner
Falling behind
G&T underachievement / Gaps in learning
Falling behind in course work
Organisation/learning /study skills
Homework Listening
Working independently
Contributing to discussions / Following instructions
Concentration
Understanding what is expected
Cultural/language misunderstandings
Starting work /Staying on task
Completing work
Social & Emotional Issues
Low self esteem/ confidence
Low self esteem/ confidence
Managing strong feelings
Withdrawn
Friendship issues
Poor social skills / Peer pressure/ gangs
Clash between home and peer culture
Co-operation in class
Disengaged from the class
Managing in a group
Difficulties in relationships with peers
Difficulties in relationships with adults / Playground issues
Lacking resilience
High Level of anxiety
Unhappy
Confused
Fearful
Behaviour
Disruptive, Disturbing others
Angry, Aggressive Frustrated / Bullying issues
Difficulties in participating
Substance abuse / Disputes with peers
Disputes with adults
Attention Seeking
Difficulty in settling into school / Health & Welfare Issues, teenage pregnancy / Attendance / punctuality
Transfer between school / Loss, bereavement, trauma / Risk of exclusion or criminal activity
Personal transitions: family issues, LAC, young carer, parental mental health, living alone
Have a concern about a child but not quite sure why

RBKC Professional Frameworks: Care, Advice and Guidance/LM Practice/Formats/LM Referral Form updated 11.04.2011