Service Request for (Pupil S Name) Enter Text
Service Request for (pupil’s name) Enter text.
Gloucestershire Hospital Education Service (GHES) provides educational support for children and young people who, as a result of their medical needs, have been or will be unable to attend school for at least 15 school days.
Referrals to GHES must be made by Medical Consultants only.
Application submitted by:Consultant’s Name:
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Service:
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Address:
Enter text / Telephone:
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Email:
Enter text. / Date:
Click here to enter a date.
Child / Young Person’s Details
D.O.B.Enter text. / Parent(s)/Carer(s):
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Address/Contact details:
Click here to enter text. / Telephone Number:
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School:
Enter text. / Year Group:
Choose an item. / On Roll:
Choose an item. / Name of School Contact (if known):
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Ethnic origin:
Choose an item. / Child In Care:
Choose an item. / Local Authority:
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SEND or EHCP
Choose an item. / Category of SEND:
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Medical Details
Medical Background / Reason for Request:Enter text.
Likely impact of the medical condition on the child/young person’s cognitive ability, learning, concentration, memory or energy levels:
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Likely impact of the medical condition on the child/young person’s social/emotional well being: (Please provide any information or indicate circumstances that would help us to deal sensitively with this individual.)
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Is the child/young person currently unable to attend school for medical reasons? / Choose an item. /
Is the child/young person’s school aware of this? / Choose an item. /
Is there anything that would help the pupil attend school now on a full or part-time basis?
Enter text.
Estimated period of absence from school from date of referral: / Choose an item.
GHES Provision or Support
Please indicate all the types of GHES provision that could meet the young person’s needs.NB: GHES cannot provide group tuition or tuition in school. / Advice or guidance to school.
Individual tuition at home.
Individual tuition outside home.
Directed independent study.
On-line learning.
Reintegration planning/support with school.
Other.
Estimated amount of provision the child/young person may be able to access from GHES.
(Bearing in mind that 1:1 tuition is more intense than classroom or group tuition) / Choose an item.
Further details if ‘Other’ selected:
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Safeguarding
Are there any safeguarding concerns regarding this young person? / Choose an item. /If yes, please give the name of the safeguarding contact: / Enter text.
Other Agencies Involved
Name:Enter text.
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Enter text. / Agency:
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Enter text. / Telephone number:
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I confirm that this child/young person is unable to attend school for the medical reasons stated above and will remain so for an estimated period of Enter text.
weeks or until reviewed on Click here to enter a date.
Consultant’s signature: Enter text.
Date: Click here to enter a date.
On receipt of this referral we may seek further background information from you or from school or other agencies involved with the young person or their family. We will respond to the referral as quickly as possible.
Please return this form and any supporting documents to
Annalise Price-Thomas
Head of Gloucestershire Hospital Education Service
Gloucestershire County Council
County Offices
St Georges Road
Cheltenham
Glos GL50 3EW
Telephone: 01242 532363
E-mail:
www.gloucestershire.gov.uk
Data Protection Act
This information is being collected for the purpose of determining the educational needs of the named pupil, but may also be shared with other relevant professionals to inform their work. The information collected may also be used for the wider purpose of providing anonymised statistical data to assist with monitoring of provision and/or determining areas of need in order to target future resources.
May 2015