PrimarySCHOOLS AND ACADEMIES
Education Support, Behaviour and Attendance Referral Form
When completed this form should be emailed to the ESBAS Area Team leaders
Please identify the main area where support is required:
Attendance Behaviour Bullying
Where bullying is identified as the main reason for a referral, please ensure that the emotional well-being questionnaire is also completed together with section 3 c/d/e/f.
East Sussex Virtual School Funded Brighton & Hove Virtual School Funded
Section 1: Child details
SchoolPartnership areaif applicable / Date submitted
Child’s name / DOB
NCY / UPN
Ethnicity
Name of parent/carer
Relationship to child
Address
Other significant adult
Address
Tel Numbers
LAC? / YES / NO
Name of LAC Caseworker
FSM eligibility? / YES / NO
English as an additional Language? / YES / NO
Safeguarding issues? / YES / NO
Name of teacher / Class
Person making Referral / Designation
Email / Phone
HAS THE PARENT BEEN NOTIFIED OF THIS / Yes / No
REFERRAL AND GIVEN PERMISSION?
Is there any reason why a home visit should NOT be made? / Yes / No
Section 2: Special Needs and Health
Statement / Statement CategoryFormal assessment underway / Needs initiating / N/A
SEN Stage / Date of entry
PSP / Date of last review
IEP / Date of last review
CAF / Date of last review
Diagnosis
Section 3: Performance indicators please from last academic term:
Percentage of attendanceFixed Term Exclusion? Number of days excluded
Part time timetable? If yes total hours in school per week?
National Curriculum Level /p level
Reading
Writing
Maths
Science
Or Early Years Foundation Stage Profile total score
Section 4: Behaviour / Attendance/Bullying Profile
a) Perceived reasons for inappropriate behaviour / poor attendance.b) How inappropriate behaviour is displayed.
c) What are the child’s strengths / positive behaviours?
d) Strategies and support provided by school and the impact of this support.
e) Outline the nature and extent of the bullying behaviour and how long this has been going on.
f) Outline the impact of the bullying behaviour on the young person.
Section 5: Other agencies involved
Service / Contact nameSection 5: Intervention requests
Nature of the intervention requested by the schoolDesired outcomes
Section 6: Checklist (Please attach)
/ Behavioural Risk Assessment / PSP
IEP / CAF
Behaviour Record / Attendance Record
Emotional well-being questionnaire attached
Signed / Date
Name
Designation
Please send to the appropriate Team Leader:
Hastings and RotherCorinna Human
3rd Floor, Ocean House,
87-89 London Road,
St Leonards-on-Sea,
TN37 6DH
Tel: 01424 726083 / Eastbourne and Hailsham
Vidyu Narayan
2nd Floor, St Mark's House,
14 Upperton Road,
Eastbourne,
BN21 1EP
Tel: 01323 747456 / Lewes Coastal and Wealden
Kate Rosling
East Block, H Floor, County Hall,
St Anne’s Crescent,
Lewes,
BN7 1UE
Tel: 01323 747484
/ /
To be completed by Education Support, Behaviour and Attendance Service.
Referral accepted? / Yes / NO / Date:Reasons for declining the referral and recommended actions