Brookside Road • Manchester M40 9GN • tel: 0161 740 1897 • fax: 0161 740 3473

e-mail: adteacher: Ms M Isherwood M.Ed., NPQH

Outreach and Inclusion Service

Referral Form

Data Protection Act 1998

The information requested on this form is required for the purpose of referring the named pupil to this service. The information provided by you may be disclosed to other professionals working with the named pupil for educational purpose.

Details of school and enquirer
Name of person enquiring: / Tel No:
School: / Date:
Address:
Email:
Previous Contact with Camberwell Park? Yes / No
If yes please give details below e.g date, name of child/children, support received etc..
Pupil Details
Name: / Gender: Male / Female
Date of Birth: / Age:
Home Language: / Year Group:
Statement: Yes / No if yes please give details: / L.A.C Child: Yes / No
CAF been completed: Yes / No if yes please give name of lead professional
Name:
Permission from the child’s Parent / Carer for this referral : Yes / No
Medical conditions / diagnosis:
If the child displays challenging behaviours please indicate triggers, exclusions, assaults etc.
What strategies/ interventions are you currently using or have tried and how long have these been in place:
Please rate your level of confidence within the above areas with 1 being not very confident and 5 being very confident, before our intervention starts:
Strategies / Interventions / Rate:
Visual Aids
Differentiation
Total Communication
Reward Systems
Behaviour Management
Work Station / Quiet Area
Other:
Please give details of any other services/professionals that are or have been involved with this child.
Name: / Role: / Date: / Level of involvement:
Educational Details
Class teacher: / Head teacher:
SENCO/Inclusion Co-ordinator: / TA Support / Key worker:
SEN Stage: School Action / School Action Plus / Intensive School Action Plus / Statement
SEN Resource Agreement? Yes / No Please Specify
Please give details of child’s current learning levels, i.e. curriculum/p levels, this information is vital to continue with this referral:
Current copy of the pupils IEP: Yes / No Please enclose
Details of request:
What kind of support / advice are you requesting:
Desired outcomes of support from this service:
What evidence do you want us to use to measure the impact? eg attendance, out of school/ in school exclusions , progress data.

UN convention on the rights of the child (UNCRC)

All our work and advice links with;

Article 23-special care and support for the children with special needs

Article 28-The right to an education

Article 20-Education should develop each child’s personality, talents and abilities to their fullest potential, as well as develop respect for parents, other members of human society, and the environment.

Registered Charity: 1111994