The Fermain Academy
-Referral Form-
Details of the StudentSurname: / First Name (s):
Gender: / Male / Female / D.O.B
Address:
Year: / 9 / 10 / 11 / Main Language:
UPN: / ULN:
Details of Parents / Carers
Surname: / First Name (s):
Title: / Mr / Mrs / Miss / Other:
Relationship to student:
Address:
Contact: / Home / Mobile
Does this person have parental responsibility:
If NO please give detail of individual with parental responsibility:
Details of the Referrer
Surname: / First Name (s):
School / Academy Name:
Role within the School / Academy:
Contact Number:
Email Address:
Please give details of the individuals you want information sent to for attendance updates and Invoices:
Attendance / Invoices
Name: / Name:
Email: / Email:
Extra Student Needs: Please Tick the following
You must inform us of all student designations so we can apply the right education and funding to the student. If you do not inform us of certain student needs, there may be additional costs or removal of placement.
Education, Health, Care Plan (EHCP) / Access Arrangements Agreed (AAA)
Under assessment for SEN (SEN) / Autism
Pupil Premium (PP) / Dyslexic
Looked After Child (LAC) / Dyscalculia
Child in Need (CIN) / ADHD / ADD
Common Assessment Framework (CAF) / English as an Additional Language (EAL)
Reason for Referral
Reasons:
Please give details for the referral and / or nature of your concern:
Integrated Services
Please give details of any support services working with the student or family
Education Psychologist / Name: / Contact:
Education Welfare / Name: / Contact:
Social Care / Name: / Contact:
Family Support / Name: / Contact:
Youth Offending / Name: / Contact:
CAMHS / Name: / Contact:
School Health / Name: / Contact:
Autism Team / Name: / Contact:
MST / Name: / Contact:
Other: / Name: / Contact:
Additional Information
Attendance / English Level / Reading Age
Exclusions / Maths Level / Spelling Age
Other useful information:
FOR THE FERMAIN ACADEMY USE
Staff Reviewing:
Met the student / Date: / Potential Group:
Home Visit completed / Date: / Options form completed:
Home / School Agreement Signed / Code of Conduct Signed / Medical form signed
Date of Induction: / To be completed with (Initial):
Number of days for induction / 1 / 2 / 3 / Days placement / 1 / 2 / 3 / 4 / 5
Travel to the Academy / Planned reintegration date:
Aims of placement:
English GCSE / Maths GCSE / Additional GCSE / 1 / 2 / 3 / Level 2 / 1 / 2 / 3 / Level 1 / 1 / 2 / 3
Re-engagement in education / Raise Attendance / Behaviour intervention / PSD Intervention
FOR THE FERMAIN ACADEMY USE
Notes:
School View: Attitude to Self, School & Others
Name …………………………………………………………………….
Student Name ……………………………………………………………
On a scale of 0-5 (0 being poor and 5 being excellent) what would you consider to be your child’s strengths or areas for improvement.
Poor0 / 1 / 2 / Average
3 / 4 / excellent
5
Does not deliberately annoy
Does not show verbal aggression
Does not tease or call names
Does not swear
Does not use physical intimidation
Is not physically aggressive and avoids fights
Values and looks after property
Does not steal
Is tolerant of others
Shows understanding and sympathy
Interacts appropriately with others
Is not a loner
Is cheerful and not tearful or depressed
Is not anxious and does not fear failure.
Moods remain stable and does not have frequent mood swings
Is patient and not easily flustered or touchy
Is not easily distracted
Can make choices is organised
Speech is coherent
Listens well
Student: Attitude to Self, School & Others
Name ………………………………………………………………..
On a scale of 0-5 (0 being poor and 5 being excellent) what would you consider to be your own strengths or areas for improvement.
Poor0 / 1 / 2 / Average
3 / 4 / excellent
5
I do not deliberately annoy people
I do not talk to people in an aggressive way.
I do not tease people or call them names.
I do not use bad language
I do not try to intimidate people who I think are weaker or smaller than me.
I am not aggressive to people and I avoid fights.
I respect my school and do not break or damage property.
I do not steal
I am patient and don’t allow others to wind me up.
I understand other people’s feelings and can show sympathy
I can talk appropriately with my friends and staff
I enjoy spending time with my friends.
I am generally happy and don’t let things get me down.
I am fairly confident and don’t worry if I can’t do something straight away.
I don’t have mood swings
I am patient and don’t get frustrated if I can’t do something.
I am not easily distracted from what I am doing
I can make my own choices and am organised
I can speak clearly
I Listen well when others are speaking.