Education Inclusion and Support Service

Education Inclusion and Support Service

1

Education Inclusion and Support Service

Louise Boxer

Vulnerable Children’s Coordinator

9th Floor, Mercury House

Mercury Gardens

Romford

RM1 3DW

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IYFAP (In Year Fair Access Panel) - Referral Form

Important Considerations before completing this form:

Please ensure all information outlined below is provided as it may delay the application if further information is required.

It is anticipated that this completed form will be shared with other multi agencies when it is considered to be in the best interests of the pupil.

Date referral made: / Date of next IYFAP:
Student’s name / Year group & DOB / Male or Female / Attendance % / KS2 Attainment
Maths / English
Pupils ULN / Pupils UPN
School name / FSM / Pupil Premium / LAC
Y / N / Y / N
School contact person / Email / Telephone
Home Address / Permanent/Temporary
Parent/carers name / Address / P / T
Home Telephone No / Parent/carer mobile number / Parent/carer email address
Family Composition
Child in Need / Y / N / Details / Historic / Y / N
Child Protection Plan / Y / N / Details / Historic / Y / N
EAL / Y / N / Details
YOS / Y / N / Details / Historic / Y / N
Drugs / Y / N / Details / Historic / Y / N
Gangs / Y / N / Details / Historic / Y / N
CSE / Y / N / Details / Historic / Y / N
Young Carer / Y / N / Details / Historic / Y / N
Police / Y / N / Details / Historic / Y / N
Student’s Ethnicity
SEND Y/N – If answer is ‘Yes’ please select which from below:
EHCP Requested Date / EP Report / ASD / ADHD / ADD / Dyslexia / Other please detail
Y/N / Y/N / Y/N / Y/N
Is pupil medicated for any of their conditions? Y/N – If ‘Yes’ please provide details
Medical Conditions Information:
Multi-Agency Services currently involved with this pupil?
Reason for Referral?
At Risk of Permanent Exclusion / Persistent disruption / One off Incident / Other
Y/N / Y/N / Y/N / Y/N
Please provide details on your selection
Number of days Fixed Term Exclusions on pupil’s record?
What outcome are you hoping for? Tick your choice below
Full Time Alternative Provision / Direction off site to avoid PEX / Managed Move to avoid PEX
(If student is in KS4 please provide subjects chosen, syllabus and exam board). / Reintegration from Olive Academy
Consent from Parent / Carer must be given for this referral to be made
Has parents’ consent been granted Y / N
What outcome is the pupil hoping for?
Has the parent submitted an i-CAF?
What outcome is the parent/carer hoping for?
What interventions have taken place?
  1. Reasonable Adjustments Y/N

Please provide details:
  1. Additional School Resource / LSA Y/N

Please provide details:
  1. Early Help Referral Y/N

Please provide details:
  1. Alternative Provision Y/N

Please provide details:
  1. Pastoral Support Plan (PSP) Y/N

Please provide details:
  1. Behaviour & Attendance Team Y/N

Please provide details:
  1. Other Multi Agency Referrals to target identified need (Reason for referral to IYFAP) Y/N

Please provide details:
  1. Have you considered applying for Social Inclusion Funding Y/N

Please provide details: /
Pupil Risk Assessment
How to calculate the results; Hazard X Probability = Level of Risk Score (1=low/16=high)
Has the pupil been known to: / Hazard
1=Rare
2=Occasional
3=Frequent
4=Persistent / Probability
1=Unlikely
2=Possible
3=Probable
4=Likely / Level of Risk / Intention
K=Known O=Opinion / Frequency
H=Hourly
D=Daily
W=Weekly
M=Monthly
O=Occasionally
R=Rarely
N=Never
U = Unaware
Self-Harm?
Abscond? (leave site without permission)
Verbally abuse other young pupils?
Verbally abuse staff?
Be verbally offensive on the basis of protected characteristic?
Use substances or alcohol?
Physically abuse other pupils?
Physically abuse staff?
Be involved in an incident where you involved the police?
Be at risk of CSE?
Damage property?
Use sexually inappropriate language?
Use sexually inappropriate action?
Carry a weapon?
Require restrictive physical intervention?
Offend?
Other?
In your professional opinion does this pupil present significant risk? If so, summarise your concerns referring to available evidence.
In your professional opinion does this pupil’s parent / carer present significant risk? If so, summarise your concerns referring to available evidence.
For LBH Office Use Only:
Pre-IYFAP Decision
Rational for decision
Date to be presented at IYFAP
Panel Decision agreed
Name of Officer completing this section
Date completed
Glossary of Acronyms
i-CAF / In Year - Common Application Form / YOS / Youth Offending Service
EAL / English is an Additional Language / LSA / Learning Support Assistant
PEX / Permanent Exclusion / EP / Educational Physiologist
CSE / Child Sexual Exploitation
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