REFERRAL FORM FOR

COAL CLOUGH ACADEMY

Please ensure all parts of the form are completed and returned to Coal Clough Academy Admissions Officer – Holly Clarke (Deputy Headteacher),

Failure to complete all the relevant sections, may result in a delayed admission for your student.

Referral Form

Please ensure all parts of the form are completed and returned to Coal Clough Academy Admissions Officer – Holly Clarke (Deputy Headteacher),

Failure to complete all the relevant sections, may result in a delayed admission for your student.

Referring School / Organisation: / Type of provision:
☐ Medical ☐ New to area
☐ Permanently excluded ☐ Respite
Main Contact: / Provision Start Date:
For CCA Staff only
Telephone Number:
Email:
PUPIL DETAILS
Surname: / Forename:
Male ☐ Female ☐ / D.O.B:
Address:
☐ LAC ☐ CAF Ref no.______☐ CIN ☐ TAC ☐ CP ☐YOT ☐ POLICE
Country of birth: / Ethnicity:
Nationality: / Home / First Language
Religion: / Single / Dual Roll:
SEN Need:
FSM: / Yes ☐ No ☐
Social worker’s name : / Social worker’s contact number:
Family support worker’s name: / Family support worker’s contact number:
ELCAS worker’s name: / ELCAS worker’s contact number:
Name of other agency involved: / Contact number of other agency involved:
Doctor:
Doctors address:
Medical history:

Parent / Carer Details

Surname / Forename
Surname / Forename
Address
Home Telephone: / Home Telephone:
Mobile no: / Mobile no:
Work telephone: / Work telephone:

Pupil Profile

Strengths: / Area for development:
Triggers: / Annual Attendance for the past 3 years (%)
(Most recent first, up until referral):
Behaviour: / Strategies:
Hobbies and Interests:

Risk Assessment

Pupil Name: / Date:
Situation / Comment
Home
Being transported
Education Venue
Unstructured time (inc.Lunch, Breaks, between lessons)
Relationship to adults
Likelihood of illegal substances
Likelihood of self harm
Likelihood of suicide attempts
Likelihood of carrying a weapon
Likelihood of risk to others
Self Control
Relationship to Peers
Adaptability to new situations
Handling stress
Conflict resolution
Following instructions
Criminal record
Likelihood of risk of arson

Funding and Service Level Agreement

(As part of the Admission Process)

Rationale

Written contracts, protocols, and partnership agreements between LAs and external providers need to be drawn up to ensure that minimum standards are met, and the safety and welfare of the young people attending AP are assured. The process of contracting, and the terms used in written contracts and service level agreements with providers, will be clearly defined and easily understood by all those involved.

Clear systems for referral and information sharing will improve the decision making process. The following referral forms and assessments will avoid duplication and support a successful placement.

Coal Clough Academy Admissions

Coal Clough Academy has established a transparent commissioning protocol with clearly defined stages for collecting information to ensure a successful transition into Coal Clough Academy.

Coal Clough Academy recognise that not all students referred will necessarily thrive within the ethos and culture of the alternative provision offered and that for some young people other forms of provision will be more suitable. For this reason there will be a full induction offered on the basis of a temporary placement for six weeks so that the suitability of the placement can be assessed.

A firm commitment on behalf of the host school and / or local authority service to provide prior all existing and available student records, related academic performance data and statutory records, e.g. attainment at KS2 and KS3, attendance, behaviour, SEN, and reasons for exclusion.

On acceptance of the referral by Coal Clough Academy, the Commissioner will enter into a contractual arrangement with Coal Clough Academy to secure the placement.

Places Commissioned By local authorities and Schools

Coal Clough Academy will work with the LA and Schools to agree number of pupil places for the following; permanently excluded, medical, vulnerable to exclusion, fixed term exclusion/ to avoid a fixed term exclusion, hard to place and school refusers.

Costings

An Education Schedule and Total Cost of Funding will be agreed at the time of referral the cost will be dependant on the service and the needs of the pupil.

BAND / DESCRIPTION
1: £4,500 per year / Low level additional needs
2: £6,000 per year / SEN Support
3: Between £6,500 - £8,000 per year / EHC Plan
4: £75 per day / Complex Needs / High Risk Needs
Other charges / Meals (Compulsory) £2.20 per day + VAT

Referral Process and Service Level Agreement

Referral types / Purpose / Referral/Review Process / Referral from / Additional Information Needed
Permanent Exclusion / To provide an education for the pupil to give the best outcome in terms of skills and qualifications. To educate re acceptable social behaviour. In appropriate cases to support the pupil back to mainstream.
(To assess if an EHCP is appropriate) / Local Authority Referral.
Admission Meeting with parents and pupil. Pupil Access attend the meeting.
Two week induction period is arranged with dates / assessments / activities
Review for one off incidents and where pupil could be readmitted to mainstream. Perhaps as a managed move initially.
There will be a six week trial period at the end of which a review will determine whether Coal Clough Academy can meet the needs of the child. / Local Authority / Pen 1
Headteacher’s Report (if possible)
Direct Referral Form (with all elements complete))
Coal Clough Academy will approach the excluding school for files once pupil is admitted.
Is a CP file in place?
Risk Assessment
Attendance Certificate(s)
Fixed Term Exclusion or alternative to Fixed Term
Exclusion.
(This option will be available from September 2016) / To provide a high standard of education to a pupil from sixth day of exclusion or as day one as alternative to FTE until their return to home school. To educate re acceptable social behaviour in a bid to prevent further exclusion. / School/ Academy Referral.
Admission meeting with parents and school for FTE onlyin excess of two weeks.
Feedback given to school at end of exclusion. / School / Academy / Consultant Letter
Direct Referral Form (with all elements complete))
Pupil Pen Profile
Learner Details Form
Is a CP file in place?
Risk Assessment
Attendance Certificate(s)
Vulnerable to
Exclusion / To provide a high standard of education whilst exploring reasons and remedies for vulnerability.
(To assess if an EHCP is appropriate) / School/ Academy Referral.
Admission Meeting with Pupil, Parents and School. Two week induction period is arranged with dates / assessments / activities
Review each half-term.
There will be a six week trial period at the end of which a review will determine whether Coal Clough Academy can meet the needs of the child. / School / Academy / A Chronology of Actions previously taken.
Direct Referral Form (with all elements complete)
Pupil Pen Profile
Learner Details Form
Is a CP file in place?
Risk Assessment
Attendance Certificate(s)
Hard to place / To provide a high standard of education whilst making an assessment of suitability to access mainstream
(To assess if an EHCP is appropriate) / Local Authority Referral.
Admission Meeting with Pupil and Parents. Two week induction period is arranged with dates/assessments/activities
Regular reviews-dependent on level of difficulty to place.
There will be a six week trial period at the end of which a review will determine whether Coal Clough Academy can meet the needs of the child. / Local Authority / Direct Referral Form (with all elements complete))
Pupil Pen Profile
Learner Details Form
Is a CP file in place?
Risk Assessment
Attendance Certificate(s)
Medical referral / To provide a high standard of education whilst the pupil is unable to access mainstream.
(To assess if an EHCP is appropriate) / School/ Academy Referral.
Admission Meeting with Pupil, Parents and School. Two week induction period is arranged with dates/assessments/activities
Review each Half-Term.
There will be a six week trial period at the end of which a review will determine whether Coal Clough Academy can meet the needs of the child. / Local Authority / Direct Referral Form (with all elements complete))
Pupil Pen Profile
Learner Details Form
Is a CP file in place?
Risk Assessment
Attendance Certificate(s)
School refuser / To explore and address the reasons for refusal and to employ a programme of re-engagement with the ultimate aim of full-time access to mainstream.(To assess if an EHCP is appropriate) / School/ Academy Referral.
Admission Meeting with Pupil, Parents and School.
Review each Half-Term with view to phasing into mainstream.
There will be a six week trial period at the end of which a review will determine whether Coal Clough Academy can meet the needs of the child. / School / Academy / Direct Referral Form (with all elements complete))
Pupil Pen Profile
Learner Details Form
Is a CP file in place?
Risk Assessment
Attendance Certificate(s)

Coal Clough Academy, Swindon St, Burnley, BB11 4PF. Tel: 01282 421142 Visit:

Referrals & Admissions: - General enquiries