/ CATHOLIC EDUCATION OFFICE BALLARAT
STUDENT SERVICES:
Referral and Parent Consent Form
This form mustbe uploaded to the Parent Permission section of the CEOB Online Referral System

Section 1: Student Details

Student VSN No:
Student Name:
SurnameFirst Name
Year Level: / UNGRPrepYear 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10 Year 11Year 12 / Date of Birth: / / / / Gender: / FemaleMale
Parent/or legal Guardian 1: / MsMrMrsMissBrFrSrDr
Title / First Name / Surname / Relationship to Student
Parent/or legal Guardian 2: / MsMrMrsMissBrFrSrDr
Title / First Name / Surname / Relationship to Student
Home Address:
No / Street / Suburb / Post Code
Postal Address:
No / Street / Suburb / Post Code
Telephone:
Home / Work / Mobile
Parent/Guardian Email Address:

This student is:

currently receiving Students with Disabilities (SWD) funding

a speaker of English as an Additional Language [EAL/New Arrival] (Please complete Appendix 1)

Aboriginal and/or Torres Strait Islander

This student:
has a DHS order relating to their care -Please specify: guardianship custody

has a Family Court Order related to their care

resides in Out Of Home Care

Please note: It is the responsibility of the Out of Home Care Case Manager to inform the school of the student’s care arrangements and legal status. (p.36)

Section 2: School Details

School Name:
Location: / E No: / E
Telephone: / Email:
Student Services Coordinator: / MsMrMrsMissBrFrSrDr
Title / First Name / Surname
Class/Nominated Teacher: / MsMrMrsMissBrFrSrDr
Title / First Name / Surname

Section 3: Referral Information:

The following questions are based on the Intervention Process, as articulated in the Intervention Framework. This outlines a process to support students with diverse learning needs along a continuum, from Identification through to Evaluation.

*= required for all services requests. The other sections will be required where the request relates to academic skills e.g. Cognitive Assessment, Oral Language Assessment, Classroom Strategy Support (academic)

Identification *
Why have you identified this student for support though CEOB Student Services?
(Also indicate if the student has a formal diagnosis or condition and if relevant, any early intervention [preschool] services that have been previously involved)
Targeted Assessment
What assessments relevant to this referral have been completed (internal and external) to date? Please list assessments and scores relevant to this service request and attach copies of reports where these have been conducted external to CEOB services.
Assessment / Comments / Scores / Benchmark / Documentation Attached
CELF-4 Screening Test
Analysis
What strengths/challengeshave your assessments indicated?
What is your primary concern for this student?
Learning and Teaching (Intervention)
What interventions/adjustments have been implemented? (attach data, current Personalised Learning Plan (PLP) and last evaluated PLP; also include information about any assistive technologies used)
Evaluation
What have the results of the intervention been? Please provide evidence (e.g. pre and post intervention assessment data).
Additional Information *
Please outline any relevant information that will further inform and assist with service provision. For example, information necessary for optimal testing conditions for the student (e.g. – reading glasses, hearing aids) and/or information related to medical conditions (medical management plan), other ongoing services currently being accessed external to CEOB (counselling, Occupational Therapy, private speech pathology), and relevant information related to custodial arrangements.

Section 4: Students with Disabilities (SWD) Program:

Please note that additional streams/services may be allocated to your child even if they have not been specifically requested by you, depending on the needs of your child as assessed by the Catholic Education Office Ballarat (CEOB).

STUDENTS WITH DISABILITIES (SWD) PROGRAM
Review of Students with Disabilities (SWD) Eligibility
Category:

Section 5: Request for Visiting Teacher Support:

VISITING TEACHER: HEARING IMPAIRMENT
(An audiogram dated within the last 12 months must accompany the referral)
Student Program Support (Hearing Impairment)
VISITING TEACHER: PHYSICAL/CHRONIC HEALTH IMPAIRMENT
(A Medical Specialist’s Report dated with the past 12 months must accompany the referral)
Student Program Support (Physical/Chronic Health Impairment)
VISITING TEACHER: VISION IMPAIRMENT
(An Ophthalmologist’s Report dated within the last 12 months must accompany the referral)
Student Program Support (Vision Impairment)
Has the student attended the Educational Vision Assessment Clinic (EVAC) to determine eligibility for access to Statewide Vision Resource Centre resources? Yes No

Section 6: Documentation

Please Note: When requesting support for a student, please attach relevant assessment information that highlights the student’s needs e.g. Literacy/Numeracy assessment data, Oral Language data, other relevant school based intervention data, other external professional’s reports (e.g. Paediatrician, Psychologist, Occupational Therapist and Speech Pathologist)

Where any concerns regarding learning exist, it is strongly recommended that a vision and hearing assessment be completed.

Please ensure you have attached the following documentation

Minutes from most recent Program Support Group meeting – where available

Required supporting information as outlined in the Referral Services section of ‘Referral Process 2015’

Other relevant information (e.g. specialist reports, analysed school assessments and recent work samples).

Current Personalised Learning Plan (PLP)and the last evaluated PLP.

Most recent school report and NAPLAN assessment (if available).

Attached Documents and Reports

As indicated above, it is helpful if reports relevant to this referral gained from other professionals e.g. paediatrician, therapists or specialists are attached to this referral. Please list documentation provided.

Author and Title Date of Report

Section 7: Service Provision and Consent

Please Note re: Service Provision

Following acceptance of this referral at the Regional Office, the most appropriate staff member and service stream to support the needs of the student will be determined. The caseworker and specific service to be provided may vary following analysis of the student’s needs. Information will be forwarded to the school detailing the caseworker and stream service to be provided initially. Schools will notify parents of the date a student services staff member will visit and the service to be provided.

Principal Name: / Principal Signature:
Date:
Class/Nominated Teacher: / Teacher Signature:
Date:

Has this student been referred previously?Yes No

Permission/consent regarding use and disclosure of personal information

I acknowledge that the information contained in and attached to this form is being collected by the CEOBfor use by officers within the CEOB, and that the information may be shared between officers within the CEOB.

I acknowledge that the information in and attached to this form is being collected for the purposes of the CEOB's Student Services Referral Service, and I consent to the information being used by CEOB officers for the purposes of the Referral Service and any related purposes. This may involve carrying out assessments of my child, including assessments conducted by any of the following experts employed by the CEOB, regardless of whether I have specifically requested such assessments from Psychologists, Speech Pathologists, Visiting Teachers and/or Education Officers – Additional Learning Needs.

I acknowledge that CEOB officers may have access to any reports held by the CEOB where a previous referral has been made in relation to my child, in addition to the information contained in and attached to this form.

I acknowledge that I have been provided with information regarding the CEOB's Student Services Referral Service and that I understand the purposes for which the information in this form is being collected. I understand that I am able to opt out of the CEOB Referral Service at any time by notifying the school formally at a PSG, by email or by letter.

Parent/Guardian Name: / Parent/Guardian Signature:
Date:
Parent/Guardian Name: / Parent/Guardian Signature:
Date:

The Catholic Education Office Ballaratis bound by the National Privacy Principles contained in the Commonwealth Privacy Act.

Permission/consent to talk to other professionals involved in student program

Please complete Appendix 2.
Appendix 1: ENGLISH AS AN ADDITIONAL LANGUAGE / DIALECT (EAL/D)

ACARA Definition of an EAL/D student

EAL/D students are those whose first language is a language or dialect other than English and who require additional support to assist them to develop proficiency in English.

EAL/D students come from diverse, multilingual backgrounds and may include:

  • overseas and Australian-born students whose first language is a language other than English
  • Aboriginal and Torres Strait Islander students whose first language is an Indigenous language, including traditional languages, creoles and related varieties, or Aboriginal English

Please provide details if the student’s first language is not English, or if there are additional languages spoken at home.

What is the student’s home language(s)?
How competent are they in this language?
With whom and when do they use this language?[e.g. Uses Vietnamese 80% of the time with mother]
[Please provide similar details for any additional languages spoken at home.
e.g. Uses Assyrian with paternal grandparents on the weekend.]
When was the student first exposed to English?
What is the student’s current preferred language?
How competent are they in this language?
With whom and when do they use this language? [e.g. Uses English 70% of the time with brother]
Where was the student born?
If not in Australia:
Please indicate the visa sub-class number where the student came to Australia on a migrant or Humanitarian (Refugee) visa:
How long has this student been in Australia?
Is an interpreter required for meetings? Yes No
If yes, please indicate the parent/carer’s language/dialect:

Where the student is not being tracked viaAusVELS please complete the EAL/D Developmental Continuum P-10 in all dimensions together with evidence of progress of targeted intervention and attach to the Student Services Referral.

The EAL Developmental Continuum P-10 is located on:

Student placement on EAL Developmental Continuum

EAL Developmental Continuum / Stage
Speaking and listening
Reading
Writing

Appendix 2: CONSENT FOR SHARING OF INFORMATION

I have provided consent for a referral to Catholic Education Office Ballarat for the purposes of the CEOB’s Referral Service and any related purposes, acknowledging that CEOB may outsource to a relevant professional in order to best meet my child’s educational needs.

  1. I consent to CEOB staff contacting the providers/agencies indicated below regarding my child.
  2. I also authorise the CEOB to provide the agencies identified below with information the CEOB has regarding my child’s health or educational needs.
  3. I consent to all relevant health and/or educational information held by the providers/agencies detailed below to be provided to the CEOB. This includes, but is not limited to hearing and vision assessments and any other health, education or early intervention reports that are considered relevant to the assessment or educational provision for my child. I understand that this information will be collected and used by the CEOB and the school to inform health and safety management strategies and educational programming for my child.

Name of Professional and/or Agency / Contact Details e.g. Ph, email, fax
Parent/Guardian Name: / Parent/Guardian Signature:
Date:
Parent/Guardian Name: / Parent/Guardian Signature:
Date:
Referral and Parent Consent Form / 1