Southwark Virtual School

Alternative Provision

Referral Form and Risk Assessment

2016/2017

Pupil Name: / D.O.B:
Year group: / UPN:
Capita ID:
Mosaic ID:
First language: / Interpreter required:
Gender: / Ethnicity: / Learning difficulty or disability: Y/N
EHCP/statement: Y/N
Medical needs: Y/N
Free School Meals: Y/N
Individual Health Care Plan Y/N
LAC Y/N
Name of Lead professional:
Name of referrer:
Contact Number:
Email address of Referrer: / Date referred:
Main parent/Carer / Relationship to pupil:
Parent/Carername & address:
Postcode: / Has the parent/carer been notified of referral?
Y/N
Parents must be notified in ALL circumstances
Parent/Carer phone number(s):
Emergency contact person:
Emergency number(s):
Last known school: / % attendance level over last term:
School exclusion history: Yes/No. If Yes please provide further information.
Perm/Fixed:
Academic Attainment (national Curriculum test results/teacher assessments):
English NC level of child or young person
Reading age of child or young person
Spelling age of child or young person
MathsNC level of child or young person
ScienceNC level of child or young person
For Year 10/11, only add subjects currently being studied:
Subjects: / Accreditation: / Exam Board:
Multi-agency support currently or historicallyinvolved:
Contact Lead / Tel no: / Date: / Assessment in place
(note if attached) / Relevant information
(please continue on separate sheet)
CAF
Inc. Lead Professional details.
Social Care LAC
Social Care CIN/CPP
Education Psychology Service
Education Welfare Service
SEN
YOT
CAMHS
Any other provision: e.g. CSE, SFFT,FFT
Reason for referral: Please be specific
Note:For medical referrals, medical evidence from medical professional must make clear that the pupil cannot access mainstream school due to illness/medical need, must be no less than 2 months old and have an anticipated end date.
Reintegration Plan: Please provide details
Note:Must detail the intended next step following period of Alternative Provision. The officer/ teacher that will lead on the reintegration plan.
Young person’s interests and what they want to do for the future:

IMPORTANT REMINDER:

Please attach:

  • Attendance and attainment information from last school/Alternative Provider.
  • CAF, where one is available.
  • Individual Health Care Plan for all medical referrals.

Would you ensure that the following risk assessment is completed.

Southwark Alternative Provision Risk Assessment

Pupil Name______Year Group______

Assessment completed by (name)______

Job Title:______Date______

Do any of the below apply?

Reason / Y/N / Reason / Y/N
Physical assault on pupil(s) / Bullying
Physical assault on adult / Drug/alcohol misuse
Sexually harmful behaviour / Theft from school premises/pupil
Persistent disruptive behaviour (despite planned interventions) / Verbal abuse against adult
Damage to property / Verbal abuse against pupil(s)
Racial abuse / Other

Key risks and mitigation measures

Referrer should attach a copy of any relevant risk assessment or behavioural support plans already in place.

If there is none in place, please complete below.

According to referrer – pupil’s risk to themselves / To be completed by Alternative Provider – suggested mitigation measures
According to referrer – pupil’s risk to other children and young people / To be completed by Alternative Provider – suggested mitigation measures
Are there any children or young people this pupil should not be placed with or who pose a risk? / Please enter their full names:

Please return this form by email to:

Laverne Noel (Deputy Head- Support and Guidance, Southwark Virtual School)

Phone: 07958 742 648/ 0207 525 4751

E-mail:

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