Surrey County Council
Alternative Education
KS3 Increasing Attendance and Engagement Programme (IAEP)
Referral for IAEP at The Willows Secondary Girls Short Stay School
Please return referral form to Rachel Wright, Head of Centre, The Willows SSS,
Southway, Guildford, GU2 8WZ or email to
1.SCHOOL DETAILS
School:Address:
Head Teacher:
SENCO:
Year Tutor:
Named School link*:
School link contact details-
Telephone:
Email:
*The Willows programmes have only been successful when schools have worked in full partnership with us to support the young person. Therefore we are asking schools to provide a named person for liaison who will monitor joint targets and disseminate information (this may be the SENCO or year head or another member of staff). Where possible, the school will invite us to reintegration meetings and will make available relevant policies and procedures so that we can support the young person’s return to the mainstream.
2.STUDENT’S PERSONAL DETAILS
Name of Student:Date of Birth:
Curriculum Year Group:
Date of admission to current school:
UPN number:
Is this student on Free School Meals?
Ethnicity:
Diagnosed medical conditions:
Date of diagnosis:
Medication & date prescribed:
On SEN code of practice? / SA / SA+ / S
Is there a PSP/PEP/IEP etc?
[please attach documents where applicable]
Number & length of any fixed term exclusions:
Does your school have a Home School Link Worker & are they involved with this family? / [please give HSLW details where applicable]
Date CAF was completed [please attach]
PLEASE NOTE: REFERRALS WILL NOT BE
CONSIDERED WITHOUT ONE
Has the PASS assessment ever been completed? [please attach documents where applicable]
3.STUDENT’S ATTAINMENT LEVELS
KS2 NC levels / Current NC levels (Teacher assessment)English
Maths
Science
4. INVOLVEMENT OF OTHER AGENCIES[please refer to school file for Primary school data]
/ Date/year and length of support or ongoing? / / Date/year and length of support or ongoing?LLS / YOT/Youth Justice
Behaviour Support / POLICE
EPS / NSPCC
EWS / ACT
SP & LANG / CONNEXIONS
CAMHS / TRIDENT
SCH NURSE / ELMA
HEALTH / TRANSLATORS
PHYS & SENS / Family Support
OUTREACH / Traveller Support
SOC CARE / Voluntary org
HOUSING / OTHER______
YOUTH TEAM / OTHER______
- REASONS FOR REFERRAL[school to complete]
Please give a summary of difficulties that this student is experiencing, and expectations from the intervention programme. Please include reasons why you believe this student would benefit from a girls only provision:
5.STUDENT COMMITTMENT
I, ______, agree to participate and improve myself
as much as possible at The Willows during the 8 week programme.
I will also try to use the skills learnt at The Willows back at school
on the other days.
6.PARENT / CARER DETAILS AND COMMITTMENT
[this person MUST reside with the student and have full parental responsibilities]
Parent /Carer:Address:
Telephone:
The Willows programmes are most successful when parents/carers have worked in partnership with us to support the young person. By signing this form (see below) you are agreeing to your child’s placement at The Willows and to work in partnership with us.
Please comment on what you hope your child will benefit from, after being at The Willows:
7.OUTCOMES[school to complete]
Expected outcomes for the student and parent/s:Expected outcomes for the school:
8.ATTENDANCE [please include SIMS attendance record if possible]
Autumn Term % / Spring Term % / Summer Term %Year 7
Year 8
Year 9
9.TRANSPORT AGREEMENT
The Willows are currently funded by the Local Authority to provide transport for students who live outside a 3 mile radius of The Willows.
By signing this referral form, schools are acknowledging their awareness that this arrangement may not continue for the entirety of the IAEP 13 programme.
Please do not submit this referral unless this has been discussed with the appropriate persons. Should you have any queries regarding this, please contact Rachel Wright, The Willows Head of Centre.
Signature ……………………………………………………….(Head Teacher)
Signature ……………………………………………………….(Parent / Carer)
Date of referral ………………………………………….
C:\winnt\temp\notesE5E6C0\WILLOWS REFERRAL DOCUMENT, KS3 - for IAEP 13.doc