Physical Difficulties Support Service

Referral Form

* Please read the Guidelines for Referrals before completing this form*

Please return completed forms to:

Sandra Paddock,

PDSS Co-ordinator

Wilson Stuart School

Perry Common Road

Erdington, Email:

Birmingham,

B23 7AT Tel: 0121 306 4806

Child’s Personal Details
Surname: / Forename: / Preferred name:
Date of Birth: / Gender:
Ethnicity: / Preferred language:
Pupil Premium: / EAL: / LAC:
UPN: / CAF :
EHC Plan/Statement
Parent(s)/Carer (s) Details
Surname: / Forename:
Home Address:
Postcode :
Tel No: / Relationship to Child: / Parental responsibility: Yes No
E mail:
Placement Details
School/Setting / Tel No :
Address / SENCO Name:
Postcode / SENCO Email :
Further Information
Specific Diagnosis and Information
Strengths and Skills
Details of Gross Motor Difficulties/Access PE
Details of Fine Motor Difficulties/Access to recording work/ICT/Practical Tasks
Please give details of all other educational agencies involved (e.g. E.P., PSS, CAT)
Please enter names with contact details below
Please give details of all medical agencies involved (e.g. hospital consultant, physiotherapist, Occupational Therapist )
Please enter names with contact details below

The information provided may be discussed with other professionals working with this pupil for educational purposes.

Parent/Carers permission must appear in writing to enable PDSS to process the referral and arrange a visit
Parental Signature / Print Name : / Date :
Referrer
Signature / Print Name :
Role : / Date :

Physical Difficulties Support Service

WE ACCEPT REFERRALS FOR CHILDREN AND YOUNG PEOPLE WITH SIGNIFICANT PHYSICAL DIFFICULTIES AS THEIR PRIMARY NEED

Information and Guidelines for completing Referral Forms

·  All referrals should be made by Educational Providers using the appropriate standard referral form.

·  We can only accept referrals from Educational Providers and settings.

·  We can only make a visit once forms are signed by parents/carers/and or designated person for looked after Children / Children in Care (Social Worker).

·  It is essential that the UPN number and SENCO’s email address is on the form.

·  Please scan and email completed forms to your relevant PDSS Base.

·  All referrals are discussed by the PDSS Team.

·  One of the Team will contact you after this to arrange an initial visit.

·  Following the initial contact appropriate support will be agreed with the setting.