Important – Please read

The Placement Request Form

The Placement Request form should be completed in full. It is the first significant step in the referral process and is designed to help the school obtain the information it needsto make a decision whether to offer a place. Having all the information at the start does make the process of placing a child at the school an easier process. To help we have created ‘drop-down’ boxes for electronic versions which you can print out and return by post.

We are aware that, often, the information is not available, either it is not known or not accessible. However, incomplete forms and lack of supporting documents can slow down the process, so, if you do not have all the information required to hand, please call us. We can then discuss the missing information and we will do our best to work around any issues that may arise.

The Mulberry Bush School is, at present, working with the Institute of Education to research the outcomes for children placed with us. Some of the questions on the form are, as well as giving the school information on the child and their family, also used to compare populations of children. These questions have pink code lettersnext to them. There is a separate letter which explains the research and seeks appropriate consent.

The Referral Process

We hope to make the process of referring and placing a child at the Mulberry Bush School as simple as possible. However, our priority is to ensure that great care is taken over decisions and that we work in partnership with the referrer. The stages, from the point of enquiry to admission are shown in the diagram on page 2.

Please take note of the advice regarding the Contract and the Permission Slips. It would leave us in an untenable legal situation if the child were to be admittedwithout the school already having received signed copies of these documents. We can only admit children once we have received these Permission Slips and the Contract.

03 Nov 2015

03 Nov 2015

Section 1: Child’s Details
Name of child:
D.O.B/010203040506070809101112/200020012002200320042005200620072008
(E) / Gender: BoyGirl
(F) / Age: 567891011 / Legal Status: S17S20S31
(L)
Does this child have an S.E.N (M) Statement? YesNo / At what age were they statemented? (N)
345678910
Nationality: / Ethnic origin: (BT – CC)
WhiteAfricanCaribbeanAfrican-CaribbeanOther BlackIndianPakistaniOther AsianChineseOther (Please specify)
Details: / Religion:
Are there any cultural/ethnic/religious needs?
Child’s UPN:
Who does this child live with currently? Mother and FatherMother and Step-fatherFather and Step-motherMotherFatherMaternal GrandparentsPaternal GrandparentsSiblingExtended FamilyFoster CarersAdoptedIn a Children's Home (O –T)
Name(s) of carer(s):
What is the current address?
Number/Street:
Town/City:
County:
Postcode:
Phone no:
Please give a brief description of the situation that has triggered this referral:
Please indicate which of the following behaviours are exhibited by the child:
Verbal abuse to adults / Verbal abuse to children
Physical violence to adults / Physical violence to children
Damage to property / Absconding
Sexualised behaviour to adults / Sexualised behaviour to children
Self-harming / False allegations
Class disruption / Extreme anger
Enuresis / Encopresis
Does this child engage in behaviour requiring physical intervention? YesNo
Has police intervention been required with this child during any incidents either at home or at school? YesNoDon't know
If ‘Yes’, please give details
Has this child ever been known to start a fire, either deliberately or accidentally?
YesNoDon't know
If ‘Yes’, please give details
(AZ)
Is the child now, or have they ever been on a Child Protection Plan/Register?
YesNo
If ‘Yes’, which category? NeglectEmotional abuseSexual abusePhysical abuse
+(if more than one)
NeglectEmotional abuseSexual abusePhysical abuse / At what age? 012345678910
Section 2: Child’s History
How many placement breakdowns has this child had in the past three years? / 01234567891011121314151617181920
How many school breakdowns has this child had in the past three years? / 01234567891011121314151617181920
Chronology of the child’s care since birth(Please attach additional sheets if needed)
Total number of placements to date: K
Age of child
(Yrs & Mths) / From
(date) / To
(date) / Placement Details
(Who child lived with, relationship to child, town)
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
Chronology of the child’s education
This section should include all school placements including playgroup, pre-school and nursery provision.
From / To / Name of Provider & Location
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months / 01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
Type of educational provision
Reason placement ended
Relevant information about education placement:
From / To / Name of Provider & Location
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months / 01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
Type of educational provision
Reason placement ended
Relevant information about education placement:
From / To / Name of Provider & Location
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months / 01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
Type of educational provision
Reason placement ended
Relevant information about education placement:
From / To / Name of Provider & Location
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months / 01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
Type of educational provision
Reason placement ended
Relevant information about education placement:
From / To / Name of Provider & Location
01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months / 01 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years0 Months1 Month2 Months3 Months4 Months5 Months6 Months7 Months8 Months9 Months10 Months11 Months
Type of educational provision
Reason placement ended
Relevant information about education placement:
Child’s Experience
(Please select one option for every question)
Has this child suffered from non-organic failure to thrive? / YesNoUnsure(AD)
Has this child suffered from neglect?
If yes, at what age was this noticed?
If yes, did this remain an ongoing issue? / YesNoUnsure(AE)
12345678910(AF)
YesNoUnsure
Has this child experienced physical abuse?
If yes, at what age did it first occur?
If yes, was this ongoing / YesNoUnsure(AG)
12345678910(AH)
YesNoUnsure
Has this child experienced sexual abuse?
If yes, at what age did it first occur?
If yes, is it suspected/known that this was sustained? / YesNoUnsure(AI)
12345678910(AJ)
YesNoUnsure
Has the child experienced a significant bereavement?
If yes, at what age did this occur? / YesNoUnsure(AN)
12345678910(AO)
Has this child been bullied?
If yes, at what age did this first occur?
If yes, was this ongoing? / YesNoUnsure(AP)
12345678910
YesNoUnsure
Has this child experienced verbal abuse?
If yes, at what age did it first occur?
If yes, was it ongoing? / YesNoUnsure(AQ)
12345678910(AR)
YesNoUnsure(AS)
Section 3: Family History
Birth mother’s name: / D.O.B. dd/mm/yyyy
Address:
Tel. No: / Mobile:
Birth father’s name: / D.O.B. dd/mm/yyyy
Address:
Tel. No: / Mobile:
How many siblings does this child have? 0123456789101112 H
Please list siblings (including half-siblings and step-siblings) starting with the eldest. I
D.O.B. dd/mm/yyyy
D.O.B dd/mm/yyyy
D.O.B dd/mm/yyyy
D.O.B dd/mm/yyyy
D.O.B dd/mm/yyyy
D.O.B dd/mm/yyyy
D.O.B dd/mm/yyyy
Was mother adopted or in care? / YesNoDon't know (U)
How old was mother when the child being referred was born? / (AB)
Does mother have any history of drink or drug addiction? / YesNoDon't know
Was there any history of drug and/or drink misuse –
a) during pregnancy?
b) during child’s first year of life?
YesNoDon't know(W)
YesNoDon't know(X)
Has mother ever served a custodial prison sentence? / YesNoDon't know(Z)
Has mother ever suffered a mental health problem?
If yes, please give details – / YesNoDon't know
Was father adopted or in care? / YesNoDon't know(V)
How old was father when the child being referred was born? / (AC)
Does father have any history of drink or drug addiction? / YesNoDon't know
Did father substance misuse during the child’s first year of life? / YesNoDon't know(Y)
Has father ever served a custodial prison sentence? / YesNoDon't know(AA)
Has father ever suffered a mental health problem?
If yes, please give details – / YesNoDon't know
Has the child been witness to any significant events?
If yes, please state what e.g. Death, serious accident -
(AM) / YesNoDon't know(AK)
Has the child witnessed domestic violence within the birth family? / YesNoDon't know(AL)
Section 4: Child’s Health
Child’s NHS No. (D)
Does the child currently receive any medication? / YesNo(BJ)
If yes, what medication are they receiving?
Does the child have any dietary needs? / YesNo
If yes, please give details -
Does the child have any ongoing health problems or allergies? / YesNo
If yes, please give details -
Does the child have a physical disability or health condition that requires paediatric involvement? / YesNo
If yes, please give details -
Does this child have ongoing Speech & language difficulties? / YesNo
Do CAMHS have any involvement with this child‘s case? / YesNo
Has this child engaged in any form of therapy or counselling? / YesNo
If yes, please give brief details –
Has this child had a full psychiatric assessment in the past two years? / YesNo
If yes, is the psychiatrist’s report available? / YesNo
Does the child have a diagnosis, or difficulties with any, of the following?
Anxiety disorders (AT) / Attachment disorder (BD)
Depression (BA) / Autism spectrum disorder (BB)
Conduct disorder (BC) / Pervasive Developmental disorder(BF)
ADHD (BG) / Epilepsy (BH)
Psychosomatic disorders / Self-harming tendencies (BE)
Substance misuse / Gender identity issues (AX)
Eating disorders (AW) / Wetting and/or soiling (AU)
Tics (AY) / Sleeping difficulties (AV)
Foetal alcohol syndrome (BI) / Tourettes
Other –
Does the child have difficulties with any of the following
Writing (BL) / Number work (BM)
Reading (BK) / Non-verbal (BO)
Dyspraxia (BN) / Dyslexia
Auditory (BQ) / Visual (BR)
Speaking/listening (BP) / School refusal (BS)
Is there any other information that you feel may be useful?

All requests for placements must be supported with the following documents

  • Chronology
  • EHCP
  • Most recent LAC Review minutes
  • Most recent PEP
  • Professional reports e.g. CAMHS reports, Educational Psychologist reports

Chronology / AttachedNot available
If you have answered ‘Not available’, please let us know when it will be available
EHCP / AttachedN/A
If you have answered ‘Not applicable’, please let us know the reasons why
LAC Review / AttachedN/A
If you have answered ‘Not applicable’, please let us know the reasons why
PEP / AttachedN/A
If you have answered ‘Not applicable’, please let us know the reasons why
Professional reports (please list below)

03 Nov 2015