Childs Full Name of young person
Preferred Name
Person making this referral / Name / Position
Address
Contact Details
Checklist for Referral
Referral form – all sections completed and signed by parents / Guardians and referring practitioner / ☐ /
Completed Pre School Inclusion Consent Form / ☐ /
Person Details
Childs Name / DOB / Gender
Ethnicity / Religion
Parent /Carer Name (s) and home address (Indicate parental Responsibility)
Home Number / Mobile
Email
Home Language
Social care Status (If Applicable)
Primary SEN Need (DfE Code) / Other (SEN) Need
Current education setting and full contact details
Name of SENCO
Name of child’s key person
Date started in setting
LEA School / Nursery Child will attend and Start Date
Number of hours young person is attending the setting
Further details
Name / Service / Date involve from - to / Involved in Assess-Plan – Do – Review Cycle
Other people/ services currently involved with this Young Person / ☐ /
☐ /
☐ /
☐ /
☐ /
☐ /
☐ /
Other people/ services previously involved with this Young Person
Attendance information
Monday / Tuesday / Wednesday / Thursday / Friday
Start Time
End time
Session total time.
Referral Information

Please describe the nature of support you feel you require to enable your setting to be more inclusive for this child.

Area of Concern:
Observations:
Please attach a minimum of 2 detailed observations specific to your area of concern (observations could include narrative, tracking, event sample etc.)
These observations should be taken at different times and in different contexts.
Please ensure you state:
Date, time, duration, context/situation, details of the activity and aims, adult involvement and child group.
Date of observation 1:
Date of observation 2:
Evaluation of observations:
(Please evaluate all observations submitted)
Following evaluation of your observations please provide supporting information:
  • What recommendations have been made?
  • How these have been implemented and over what period of time?
  • What learning outcomes is the child is working towards and progress made towards targets?
  • How planning has been differentiated?
  • Ensure you detail what strategies/resources are being deployed and by whom?

Initial concerns raised by (please name and state capacity e.g. parent, staff member, other agency)
Level of involvement from the Health Visitor
  1. Universal ☐
  2. Universal Plus☐
  3. Partnership Plus☐

What is working: the impact of effective strategies and interventions on education and wider outcomes
What was not working: reasons why strategies and interventions have been discontinued.
How strategies and interventions are evaluated
Child’s progress in Early Learning Goals
Please summarise progress when last assessed
Prime Area / Aspect / Date assessed / Child’s age
Year : Month / Dev level
Communication & language / Listening & attention
Understanding
Speaking
Personal, social & emotional / Making relationships
Self-confidence & self-awareness
Managing feelings & behaviour
Physical development / Moving & handling
Health & self-care
Specific areas / Literacy
Mathematics
Understanding the world
Expressive arts & design
Authorisation
Authorisation for the Request (setting manager) / Name / Position
Date / Signature
Agreement of Parent(s)/ Carer(s):* / Name(s) / Date
Signature(s)
Date submitted to the Local Authority

Please return to:

Early Support Panel

Pre School Inclusion & Portage Team

Floor 3, Civic Office

Waterdale

DONCASTER

DN1 3BU

A parent or person with parental responsibility must complete and sign the ‘Consent’ section.

Full Name / DOB
Ethnicity / Gender
Address
Postcode / Contact Number
Setting / Key Contact
Name of person (s) with parental responsibility
Address if different
Contact Number
Is this child / young person “looked after” by the Local Authority?
If Yes: / Local Authority Responsible
Social Worker Name / Social Worker Contact
Contact Name
GDA/ASAP
Service for children with Hearing Impairment
Service for children with visual impairment
SAID SEND Service
ASCETS
G.P.
Other
Children’s Centre
Speech & Language Therapy
Physiotherapy
Occupational Therapy
Social Care
Educational Psychology Service
Health visitor
Has anEarly Help Assessment been completed for this young person? / Yes / No
If Yes: Date Early Help Assessment was completed
Name of Lead professional
Position
Contact Details
Parental consent: I give permission for the Pre School Inclusion team/Doncaster Portage service to seek information from other professionals who may have relevant information about my child and to store, process and share information with appropriate professionals in compliance with Data Protection laws. I also give permission for members of Pre School Inclusion Team/Doncaster Portage service to work with my child, individually or in a group and that I have the right to be present at any individual session if I wish. I understand that I can withdraw part or all of this consent by writing to the Pre School Inclusion Team/Doncaster Portage service at any time
Name of person signing
Relationship to young person
Signature
Date Signed

Early Years Panel

Pre School Inclusion & Portage Team

Floor 3, Civic Office

Waterdale

DONCASTER

DN1 3BU

Email –