From April 2016

REFERRAL TO SOCIAL EMOTIONAL AND MENTAL HEALTH PANEL
Confidential to partner agencies
Name of School: Date:
School contact name:
Telephone:
Email:
PUPIL DETAILS
Full name: / DoB:
Address: / Contact Tel No(s):
Name(s) of parent(s) / carer(s):
Current Year Group: / Attendance record current year (%)
please indicate if part time provision: Y / N
If yes please attach details and re-integration plan.
EHA Unique No: (if applicable) / Date:
TAF dates :
SAFEGUARDING
Are there current safeguarding concerns relating to this child or family? / Y / N
Is the child on a Child Protection Plan ? / Y / N
Are there concerns around Child Sexual Exploitation relating to this child or family? / Y / N
Are there concerns around PREVENT / Radicalisation / Violent Extremism relating to this child or family? / Y / N
Are there any other safeguarding concerns you may have? / Y/N
If the response is YES to any of these please provide further information in a confidential attachment

HOME CIRCUMSTANCES

Living with parent(s) / Living in foster home
Living with relative(s) / Living in children’s home
Other arrangements / Privately fostered
Particular vulnerabilities e.g. Traveller family, health, EAL etc.
Pupil’s views and wishes:
Parent(s) / Carer(s) views and wishes:

SCHOOL HISTORY

Current School: / From / To
Previous Schools/ nursery is applicable:

Record of Exclusions

Date / Reasons / Number of days/sessions

Assessment Information

Baseline
Reading / Writing / Maths / Science
EYFS
Key Stage 1
Key Stage 2

WBS: working below the expected standard for their age

WTS: working securely towards the expected standard for their age

GDS: working at greater depth within the expected standard

Learning Needs / Emotional, social and behavioural needs

Please provide a summary of the child’s needs as they present in school
Please provide a brief summary of life events impacting on the child
Please provide a summary of support provided by the school if not covered in separate, detailed attachments
Nature of support / Impact / Cost

Support provided by other professionals/services

Date / Nature of involvement / Contact
Educational Inclusion and Partnership Team
Education Psychology
Children’s Social Care
Virtual School
Camhs
Early Help Team
Independent Behaviour Support Services;
Please specify
School Nurse
Community Paediatrician
Youth Offending Service
Other (please specify)

What outcomes do you hope for from this referral?

Action / Intended impact

Signed………………….…………………(Headteacher) Date……………….

Print name……………………………….

Please include copy of any other relevant supporting information to support your referral

Please submit this referral form, and attachments to

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