Specialist Teachers for Inclusive Practice

South East Surrey

Pupil Referral Form

PLEASE ENSURE YOU HAVE DISCUSSED THIS REFERRAL WITH YOUR ALLOCATED STIP PRIOR TO COMPLETION

Name of Pupil: / M / F
Date of Birth: / Primary Need:
Year Group: / Code of Practice Stage: / SS / EHCP
Parent/ Carer: / Address:
Tel: / Postcode:
School: / E Mail
Postcode: / Telephone
SENCO / Inclusion Leader / Class Teacher
Additional Information: / Professional Involved:
At risk of PEX: / CAMH’s
Fixed Term Exclusions: / SALT / OT
EAL:
First Language: / EP
Disability Register: / STIP (BS / LLS)
LAC: / REMA
Pupil Premium: / PSSS / VI / HI
Ethnicity: / Health
Attendance Record: / Other
Primary Areas of Concern:
Identify the pupil outcomes you wish to achieve from STIP involvement:
Pupil learning and Behaviour Profile:
Provide details of age related levels according to the schools own tracking system:
Results of school based diagnostic tests with dates:
Compulsory Information to be attached (please tick):
Provision Map / SEND Support Arrangements (with evidence of recent and reviewed targets). / Behaviour log (BS referrals only) / SLCN Checklist
Additional Information (please tick):
Strengths & Difficulties Questionnaire / Phonics Screen / Behaviour Plan / Risk Assessment
Details of previous interventions:
List successful strategies:
List unsuccessful strategies:
Pupil perspective:
How does the pupil currently view themselves in school?
What are the pupil’s key motivators and main interests?
Parental / carer involvement:
The aim of the Specialist Teachers for Inclusive Practice (STIP) is to give additional external support to your child’s school in order to help your child achieve their best. Our involvement can take a variety of forms. This may range from a telephone problem solving discussion with the school, to a full on site consultation. The Specialist Teacher, in liaison with school staff will decide upon the appropriate level of intervention as an outcome of the initial phone conversation. The school will keep you informed of the level of intervention agreed.
I have read the referral and I give permission for the Area Specialist Teachers to have involvement with my child and to share the relevant information with other members of the team and the Education Psychology Service.
Parent Name: ______Signature: ______
Date: ______
Please comment on what you hope this intervention will achieve.
OFFICE USE ONLY / Work Assigned to: / Date Assigned: / Level of Intervention:

Please return to:

Wendy Mumford, Senior Lead South East Area, Schools and Learning, Children, Schools and Families Directorate,Surrey County Council, Consort House, 5-7 Queensway, Redhill,Surrey. RH1 1YB

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