OFFICIAL – SENSITIVE [PERSONAL]
Suffolk Behaviour Support Service
TRANSITION SUPPORT OUTREACH REFERRAL FORM (2017)
Data Protection Act 1988
Information given by you is needed to help BSS staff in supporting pupils and maintaining records of pupils with whom BSS is involved. The information is kept, in part, on a computerised database and, in part, as paper records. This information may be shared with other agencies.
First Name / Last NameDOB / UPN
Year Group / Class / Male / Female
Names of parent(s)/carer(s)
Child’s current address
Postcode / Home Tel No / Mobile
Parents’ address (if different from child)
Postcode / Home Tel No / Mobile
CurrentSchool: / New High School:
Parent(s) or carer(s) must give permission for this referral.
Have they done so? Yes No
Referral discussed with parent(s) or carer(s) / By / On (date)
Parent(s) signature(s) – Hard copy retained in school / YES/NO
Is the pupil subject to a Child Protection Plan? Yes No
Name of Senior Designated Professional/s in school:
Is the pupil Looked After by the Local Authority? Yes No
Is the pupil receiving Free School Meals? Yes No
Is there a CAF/TAC in place for this pupil/family? Yes No
Ethnic Origin (please enter the appropriate ethnic origin code as used on your school database)
Language spoken at home Interpreter needed? Yes No
IEPs/IBPs / PSP / Statement
Learning strengths/difficulties:
Is the pupil attending full time? Yes No
Has the pupil been excluded? Yes No
Date of exclusion(s)
Please give details of any health related difficulties:
Please record all other agencies involved:
Agency / Contact name / Nature of involvement
Main concerns relating to transition:(i.e. anxieties/relationships/risk of exclusion)
Current scaled level of concern
1 2 3 4 5
Please circle appropriate point on scale note: 1 = low 5 = high
Pupil’s interests/strengths/assets:
Print name of person completing this form
Position in school
Signature / Date
**Footnote
Requests cannot be processed without parental consent
Completion of this form does not guarantee support at this time.
It is essential that this form is accurate and complete. Incomplete forms will be returned. This may cause a delay in the work commencing. Completed forms should be returned to:
REFERRALS TO BE SENT BY 15TH MAY 2017 TO THE APPROPRIATE BSS INBOX:
Northern Area:
Southern Area:
Western Area:
Page 1 of 2 BSS – July 2017 OFFICIAL – SENSITIVE [PERSONAL]