Specialist Learning Support - (Autumn2015)

SINGLE POINT REFERRAL FORM (V12)

SECTION 1: Child/Young Person
Surname: / First Name(s):
Previous Names (AKA): / Unique Pupil No:
Address:
Name of School / Not on a school roll (CME)
Male / Female / Date of Birth: / Year Group:
Ethnic Code: / Nationality: / Religion:
Child/Young Persons first language or preferred means of communication:
Interpreter/Signer Required for Child/Young Person: / YES NO
Immigration Status / Asylum Seeking / Refugee Status / Exceptional Leave To Remain
SECTION 2: Person Completing This Form
Mr/Mrs/Miss/Other: / Full Name:
Designation/Title: / Contact Number:
Date form completed: / Email Contact:
Please note all SPR forms to be agreed by a senior leader within the school/service before submitting the form.
In the case of a permanent exclusion the form must be signed off by the Head teacher
Name of senior leader:
SECTION 3: Specialist Learning Support Required
SERVICES DIRECTORY: Link toDirectory of Pupil Referral Service's Single Point of Referral
If you believe more than one service is needed please specify in the ‘outcomes’ box, in section 4 of this form, which additional services may be required and provide any additional information that may be required for referral to these services. (Within the Services Directory – required additional information is specified)
BESD REFERRAL KS1, KS2 and KS3 / KS1 KS2 KS3
BESD REFERRAL KS4
Please complete Appendix 2 / In school support
Alternative provision
MEDICAL REFERRAL / KS1 KS2 KS3 KS4
ENGLISH AS ADDITIONAL LANGUAGE /
INTERNATIONAL NEW ARRIVALS / KS1 KS2 KS3 KS4
DAY 6 REFERRAL FOLLOWING PERMANENT EXCLUSION
Please complete Appendix 1 Day 6
Head teacher to contact Clare Davies prior to completion of this form / KS1 KS2 KS3 KS4
Has the Parent/Carer agreed to this referral? / YES NO
If NO – please indicate reason:
Has the Parent/Carer consented to share information: / YES NO
If NO – please indicate reason:
Consent sharing agreement form signed (appendix 3 in Guidance – form to be retained by referrer)
If no please state the reason why and which agencies are not to be contacted: :
Has the CHILD/YOUNG PERSON been informed of this referral? / YES NO
If NO – please indicate reason:

Link to Guidance Document Please readBEFORE completing this referral form. Where appears click to apply preference.

SECTION 4: Additional Needs
Within this section schools should summarise interventions applied and strategies adopted to address the identified need/s. Please include a summary of outcomes for the child following specific interventions. Please be clear around your concerns, evidence based and indicate how the service might support the child/family & school.
REASON FOR REFERRAL:(Nature of Concern)
Please specify reason for referral and/or nature of your concern:
ACTIONS TAKEN:(School Interventions) / OUTCOMES:(Following School Intervention)
Please specify actions you have taken:
/ Please indicate outcomes following school intervention:
AIMS OF REFERRAL (How Services might support the CHILD/FAMILY/SCHOOL):
Please indicate how the service or services you have requested can help achieve these outcomes:
SECTION 5: Integrated Working (If applicable):
Where the involvement of several agencies would help to address a child or young person’s needs, it may be appropriate to assess those needs using Single Assessment, this provides a holistic assessment and enables practitioners and/or multi-agency teams to provide a coordinated response to additional needs.
The Single Assessment is a useful tool for practitioners to assess the child/young person’s additional needs.
Children who have additional needs may require extra support to help them in the following areas:
  • The child's developmental needs;
  • The parents' or caregivers' capacity to respond appropriately to those needs; and
  • The wider family and environmental factors.

CONTACT DETAILS MUST BE INCLUDED (NAME/ADDRESS/TELEPHONE NUMBER)
Please include referrals made to other agencies where a referral was NOT successful or the child has been placed on a waiting list
AGENCY INVOLVEMENT: Please provide contact details including lead professional, actions following agency involvement and outcomes.
Education Psychologist / Contact:
Actions: / Outcomes:
Attendance and Pupil Support Service / Contact:
Actions: / Outcomes:
Family Support and Child Protection Services (Social Worker) / Contact:
Actions: / Outcomes:
Mental Health Services CAMHS CHEWS / Contact:
Actions: / Outcomes:
Health / Contact:
Actions: / Outcomes:
YOT / Contact:
Actions: / Outcomes:
Other please specify
Actions: / Contact:
Outcomes:
SECTION 6: Parent/Carer & Child Views
Within this section schools should summarise the views of the parents/carers, (through consultation), and seek to establish the views and concerns of the child.
CHILDS STRENGTHS/INTERESTS:
Please indicate areas of success for the child, (what the child does well):
VIEWS OF PARENTS/CARERS: / VIEWS OF THE CHILD:
Please indicate the views of parents/carers:
/ Please indicate the views of the child:
SUPPORTING INFORMATION: DO NOT SEND THIS INFORMATION
(This information should be ready and available at the initial planning/consultation meeting)
Please indicate which of the following information, reports and assessments you have to support this referral:
BEHAVIOUR RECORDS / REVIEW REPORTS / My Support Plan
HEALTH CARE PLAN / ADDITIONAL NEEDS PLANS / PSPS ILPS
For medical referrals: Consultant Advice
Other - Please specify : / Other medical report: / Attendance Information
DATA PACK or progress tracker (To include Current NC Attainment and Target Grades and Progress Tracking)
SECTION 7: Child/YoungPerson Information(PLEASE COMPLETE IN FULL)
CURRENT ATTENDANCE (%): / ATTENDANCE LAST ACADEMIC YEAR (%):
READING AGE / TEST DATE
PLEASE PROVIDE ANY INFORMATION YOU HAVE AROUND ATTAINMENT & PROGRESS
Current NC ATTAINMENT LEVELS (please indicate if child is making expected progress)
ENGLISH: / MATHS: / SCIENCE:
STANDARDISED READING AGE: / STANDARDISED MATHS AGE: / STANDARDISED SPELLING AGE::
WHICH YEAR GROUP EXPECTATION IS THE CHILD CURRENTLY WORKING CONFIDENTLY WITHIN? / MATHS: / READING: WRITING:
COGNITIVE ABILITIES TEST (CAT): V / N / NV
FISCHER FAMILY TRUST PUPIL ESTIMATES
5A*-C (EM) % / 5A*-C % / 5A*-G %
EXCLUSIONS (Days excluded this academic year) / Number of exclusions
EXCLUSIONS (Days excluded LAST academic year) / Number of exclusions
IS THE CHILD ENTITLED TO FREE SCHOOL MEALS: YES NO
DOES THE CHILD ATTRACT PUPIL PREMIUM FUNDING? YES NO
INTERVENTIONS
USING PUPIL PREMIUM FUNDING: / OUTCOMES OF THE PP INTERVENTIONS:
LOOKED AFTER CHILDREN: (Children & Young People in Care)
Is the CHILD/YOUNG PERSON LOOKED AFTER? / YES NO PEP DATE:
Social Worker
Has the school applied for additional LAC funding (Pupil Premium Plus) / YES NO
DISABILITY:
Is this child disabled? YES NO / Nature of disability:
SPECIAL EDUCATIONAL NEEDS:
IS THE CHILD ON THE SEN REGISTER? YES NO
PLEASE INDICATE SEN STAGE: / SEN SUPPORT / SEN STATEMENT / EHC PLAN
REQUEST FOR EHC ASSESSMENT TO LA
Please consider the information attached in the link prior to a request for EHC assessment:
/ DATE REQUEST MADE TO SENACT:
SEN Guidance School Based Support:

INTERNATIONAL NEW ARRIVAL:
Date of entry into UK
Has the child received schooling in country of origin? YES NO How many years?
Has the child ever received schooling in the UK? YES NO When How long?
Can the child use English? Reading YES NO Writing YES NO Speaking YES NO
Can the child use a language other than English? Reading YES NO Writing YES NO
Speaking YES NO Which language(s)
Has the child ever been identified as having any special need? YES NO ( detail)
YOUNG CARER:
Is the CHILD/YOUNG PERSON a YOUNG CARER? YES NO
CONCERNS:The Single Assessment is a useful tool for practitioners to assess the child/young person’s additional needs.
Children who have additional needs may require extra support to help them in the following areas:
  • The child's developmental needs;
  • The parents' or caregivers' capacity to respond appropriately to those needs; and
  • The wider family and environmental factors.

OUTCOME OF SINGLE ASSESSMENT:
Indicate YES if a Single Assessment would help. YES NO
OTHER ASSESSMENTS: LEAD PROFESSIONAL:
SINGLE ASSESSMENT CHILD IN NEED (SECTION 17 ASSESSMENT) CHILD PROTECTION PLAN
Are there CHILD PROTECTION RECORDS on this child? / YES NO
SECTION 8: Parent/Carers
Mr/Mrs/Miss/Other: / Full Name:
Relationship to CHILD/YOUNG PERSON: ADDRESS:
CONTACT DETAILS/TELEPHONE NUMBERS:
1st LANGUAGE: Interpreter/signer required for Parent/Carer: YES NO
Does this person have Parental Responsibility: YES NO ( if NO – complete below)
Name of person with Parental Responsibility and contact details:
Other SIGNIFICANT members of the family:
NOTE: If you feel other significant members of the family are relevant and need to be raised at the Single Point Referral Panel please give details above. (see Guidance to Schools)
INFORMATION SHARING ADVICE
  1. Be open and honest with the person (and/or their family where appropriate)

  1. Share with consent where appropriate

  1. Consider safety and well-being

  1. Ensure that the information you share is necessary for the purpose for which you are sharing it

  1. Keep a record of your decision and the reasons for it

  1. Remember that the Data Protection Act 1998 is not a barrier to sharing information

  1. Seek advice if you are in any doubt

Please refer to the Guidance regarding / ELECTRONIC TRANSFER

ALL forms should be transferred through the schoolANYCOMMS box.

APPENDIX 1– DAY 6 to be completed for all permanent exclusions.
Thank you for providing detailed and accurate information. The information is needed to arrange appropriate alternative provision from day 6; it will also inform the allocation of a new school through the Fair Access Panel and/or Alternative Provision through the Single Point of Referral Panel
Date of Permanent Exclusion:
Date notified LA / Day 6 Provision start date: / Governors’ DC Date:
Reason for exclusion: Please provide FULL DETAILS of the current exclusion, i.e. what behaviour/incidents lead to this exclusion:
Reason for Exclusion: (Please double tick main reason/single tick supplementary reasons)
Persistent Disruptive Behaviour / Verbal abuse/threatening behaviour against adult
Physical Assault against adult / Verbal abuse/threatening behaviour against pupil
Physical Assault against pupil / Theft
Bullying / Racist abuse
Drug and alcohol related / Sexual Misconduct
Damage / Other:
If the exclusion is drug related, please identify the nature of the incident
Dealing on the premises / Other drug related
Possession on the premises / Alcohol/tobacco/solvents
If the child/young person is a health & safety risk please provide contact details for a person in school who can contribute to a risk assessment.
Is a risk assessment required? YES Contact in school for risk assessment NO
Links to exclusion guidance and information:
DfE information about the instances when the exclusion of a pupil from school is appropriate, and the procedures the school must follow. / Link to DfE Exclusion Guidance
Advice related to exclusion for parents:Coram leaflet
Coram Children’s Legal Centre: Coram leaflet
Telephone:08088 020 008 Monday to Friday, 8am to 8pm
APPENDIX 2 – to be completed for all referrals to KS4 Alternative Provision
EXAM INFORMATION
UNIQUE CANDIDATE IDENTIFIER (UCI)
NO UCI ALLOCATED:
Have you applied for access arrangements for public examinations for this young person? YES NO
If YES, please provide details:
EXAM ENTRIES / COURSES STUDIED
SUBJECT / BOARD / CURRENT STATUS (i.e. work completed and modules taken, exam entries) / Predicted Grade
ADDITIONAL INFORMATION
What does the young person do well and enjoy?
What are the young person’s ambitions/hopes for the future?
Are there any reasons to suggest that the young person might exploit others (bullying, intimidation, offending and so on)? / YES
NO / Please specify if YES:
Are there any reasons to suggest that the young person is “a victim” and might be exploited? / YES
NO / Please specify if YES:
Are there other young people who s/he should not mix with? / YES
NO / Please specify if YES:
Is there evidence of drug, alcohol or substance misuse? / YES
NO / Please specify if YES:
Should reintegration seem to be appropriate in the future, will you be prepared to readmit the young person subject to negotiation? / YES
NO / Comments:
Is the young person currently enrolled in a collegiate course/engagement programme/NEXUS? / YES
NO / Please provide details if YES:
Could the young person continue with this activity whilst attending alternative provision? / YES
NO / Comments:
Type of provision preferred
All our provisions offer functional skills in Maths and English to Level 2, some offer a more practical curriculum, others offer a more academic curriculum with GCSE qualifications. Please indicate what type of provision would be most suitable for the young person. / Rank 1 to 3
A more academic offer following a GCSE syllabus, more like school but in a smaller setting and with smaller groups
An offer combining some academic work with more practical subjects.
An offer with a strong vocational focus
Other relevant interests:
Any additional information you want to provide:

Please complete consent form.

PARENTS / CARERS CONSENT TO REFERRAL, INFORMATION SHARING AND SUPPORT FROM KS4 PARTNERSHIPS
This section of the form should be completed with parents/carers.
Attendance at most of the alternative resources involves young persons travelling to and from by public transport. Are parents/carers prepared to allow this? Costs are usually covered.
Is the young person capable of travelling independently? YES NO
Parents/carers declaration:
I agree that this referral may be made and that the information given on this form, as well as any relevant information from other sources, may be made available to the panel. All of the information in this referral may be shared with other agencies and alternative providers involved. Throughout the placement process and during the placement in alternative provisions additional help for my child may be provided by the school in partnership with the Pupil Referral Service.
Signed:
Name (Printed) Date:
Has parents’ / carers’ signature been obtained and dated? YES NO
School to retain a signed copy.
HEAD TEACHER’S CONSENT:
IF ON A SCHOOL ROLL – the Headteacher’s agreement to the referral must be obtained.
Head Teacher’s consent:I agree that this referral may be made and that the information given on this form, as well as any relevant information from other sources, may be made available to the panel.
All of the information in this referral may be shared with other agencies involved. I agree to the funding arrangements.
Signed (or electronic signature):
Name (Printed) Date:
Has the Head Teacher’s signature been obtained and dated? YES NO