SHAFTESBURY HIGH SCHOOL

INTERVENTION PROGRAMME/MEDICAL REFERRAL FORM

Please complete & forward to the Headteacher
Please Select Type of Referral Place Requested: / Full Intervention Programme
8 Week Intervention Programme
Medical Referral
ALL INFORMATION MARKED * IS MANDATORY & MUST BE COMPLETED. INCOMPLETE FORMS MAY CAUSE DELAYS
Pupil Details:
*Surname: / *Legal Surname:
*Forename: / Middle name:
*Address
- including postcode: / *Date of Birth: / --
*Gender: / MaleFemale / *Year: / 7891011
*UPN:
*ULN:
*Free School Meals? / Free School MealPaid School MealSandwichesHomeOther
*Pupil Premium Indicator? / YesNo Please state which: FSM (Deprivation) PPService Child PPLooked After Child PP
*SEN Category & Need Type: / C - Concern (SA)K - SEN Support N (SA+)E - EHC Education Health Care Plan (S)
*Need Type: / SMEH - Social Mental & Emotional Health (BESD)NSA - SEN Support but no Specialist Assmt of NeedMLD - Moderate Learning DifficultiesSLD - Spec Learning DiffSLD - Severe Learning DiffSLCD - Speech,Lang & Comm DiffASD - Autistic Spectrum DisorderPMLD - Profound & Multiple Learning DiffVI - Visual ImparementHI - Hearing ImparemtentMSI - Multi Sensory ImparementPD - Physical DisorderO - Other Difficulties/Disabilities
*Medical/Dietary note: / None / *Ethnicity: / NOBT - Not ObtainedWBRI - White BritishWIRI - White IrishWIRT - White Traveller of Irish HeritageWROM - White Gypsy/RomaWOTH - Any other White backgroundMWBC - White & Black CarribbeanMWBA - White & Black AfricanMWAS - White & AsianMOTH - Any other mixed backgroundAIND - IndianAPKN - PakistaniABAN - BangladeshiAOTH - Any other Asian backgroundBCRB - Black CarribbeanBAFR - Black AfricanBOTH - Any other black backgroundCHNE - ChineseOOTH - Any other ethnic backgroundREFU - Do not wish an ethnic category recorded / Religion: / AnglicanBaptistChristianHinduJewishMethodistMuslimNo ReligionRoman CatholicSikhUnclassifiedUnited Reform ChurchOther
*Looked After Child?: / YesNoWhich Authority / *Pupil Attendance: / %
Is there a CAF?: / YesNo - If ‘Yes’ please give details: / CAF Date: / --
Contact Details:
*Parent/Carer: / MrMrsMissMsOther / *Tel:
& Address if different to pupil: / *Mobile:
*Main Email:
Referring School:
*School Name & No.: / Albany Academy - 09504All Hallows High School - 07106Balshaws CofE HS - 07101Bishop Rawstorne Academy - 09502Brownedge St Marys CHS - 07105Holy Cross - 09103Hutton Grammar School - 07109Leyland St Marys High School - 07102Lostock Hall Academy - 07501Parklands Academy - 09505Penwortham Girls - 07111Penwortham Priory Academy - 07502Southlands High School - 09101St Michael's Academy - 09501Tarleton Academy - 08502Walton-le-Dale High School - 07107Wellfield High School - 07104Worden Academy - 07503 / *Tel:
*Contact: / *Email:
Parental Consent Obtained for referral?: / YesNo / Date: / --
Reason for Referral:
PUPIL DATA: / Maths / English / Science / IT
KS2:
(Decimal Levels):
KS3:
(Decimalized/Sub Levels):
KS4 - FFTD Pupil Estimate Report, All Subjects KS2 or KS3 (most recent/available)
Verbal / Quantitative / Non-Verbal Reasoning
CAT Scores:
Or if unavailable any other Assessment Systems estimation e.g. MidYsis, YeLLis and/or attach supporting information.
Are there any access arrangements for exams? YES* NO (*If yes please send copies with this referral.)
Please list any exams and their respective boards being studied:
Please complete the attached GCSE Subjects form in full
Agencies Involved (please tick & give details):
CAPS / EP / CAMHS / CIS(SS) / Family Support / Police / YOT / YPS / Youth & Comm / Mentor
Signature: / Date: / --
GCSE Exam Subjects Form:
Pupil Name: / Last School Attended:
Exams Officer: / NC Year:
ULN: / UCI:
Subjects / Tier / Board / Coursework / Subject Teacher
Higher / Foundation / Yes / No
English
English Literature
Mathematics
Core Science
Additional Science
ICT
History
Geography
Religious Studies
MFL
Drama
Child Development
Physical Education
Others i.e. BTec/Funct Skills etc
Additional Notes:

Check or website for further information and access to this form

Address: Weldbank Lane, Chorley, PR7 3NQ. Tel: 01257 249803, Fax: 01257 261353
E-mail: and

Revised January 2015 (a)