CHELTENHAM & TEWKESBURY ALTERNATIVE PROVISION SCHOOL
REFERRAL FORM – PRIMARY & OUTREACH
ALL SECTIONS TO BE COMPLETED BEFORE SUBMITTING TO
CHELTENHAM & TEWKESBURY ALTERNATIVE PROVISION SCHOOL
REFERRAL FORM – PRIMARY & OUTREACH
(Please complete every section of this form to avoid delay)
Start Date(office use only) / UPN / GENDER / MALE/FEMALE
ULN
Pupil’s Name / DOB / YEAR GROUP
Parent(s)/ Carer(s) / PARENTAL RESPONSIBILITY / YES/NO / ETHNICITY
FIRST LANGUAGE
RELIGION
Address / C.I.C
(If Yes please give start date) / YES / NO
PUPIL PREMIUM / YES / NO
SERVICE FAMILY / YES / NO
Telephone No
MY PLAN + / EHCP PENDING / REVIEW DATE / PRIMARY NEED
EHCP / DATE ISSUED / PRIMARY NEED
MULTI-AGENCY WORKING AND SUPPORTING DOCUMENTS
AGENCY / SERVICE INVOLVED / NAME OF PROFESSIONAL / CONTACT DETAILS / DOCUMENTS / REPORTS / ATTACHED?
BASELINE DATA
CURRENT LEVELS / ENGLISH / PREDICTED LEVELS AT END OF KEY STAGE / ENGLISH / ATTENDANCE % THIS ACADEMIC YEAR / PRESENT
MATHS / MATHS / AUTHORISED
SCIENCE / SCIENCE / UNAUTHORISED
HOW MANY DAYS OF EXCLUSION HAS THIS PUPIL HAD THIS YEAR?
CATS
VRQ / VERBAL / NON VERBAL / QUANTITIVE / MEAN SAS
WHY ARE YOU REFERRING THIS PUPIL TO THE APS?
WHAT ARE YOU HOPING FOR AS AN OUTCOME OF THIS SUPPORT FOR THIS PUPIL?
INFORMATION GATHERING
PUPIL STRENGTHS:
PUPIL STRENGTHS:
Attainments in Reading - (e.g. Which colour band is currently being read? Is the child a free reader? Are you using any specific interventions to develop skills in reading? Which key words can s/he read on sight?)
Attainments in Writing – ( Is the child able to word build, use punctuation, use story planners etc.? Can s/he use tenses, connectives etc.?)
Attainments in Numeracy – (Is the child able to count accurately, add, subtract, multiply or divide? Can s/he recognise 2D & 3D shapes, problem solve?)
If you were to set one target for literacy, what would it be?
If you were to set one target for numeracy, what would it be?
If you were to set one target for behaviour, what would it be?
Any further information:
ACADEMIC TARGETS
What is the expected progress for this student whilst at APS?
English / Maths
1.
2.
3. / 1.
2.
3.
SOCIAL
1.
2.
3.
TEACHER CONTACT INFORMATION
TEACHER CONTACT
TEACHER EMAIL
WHAT MEASURES HAVE THE SCHOOL ALREADY TAKEN TO SUPPORT THIS PUPIL? HOW SUCCESSFUL HAVE THEY BEEN?
ANY ADDITIONAL INFORMATION THAT WILL BE USEFUL FOR US TO KNOW:
HAVE THE PUPILS’ NEEDS BEEN DISCUSSED WITH APS STAFF? / YES / NO
ARE THERE ANY SAFEGUARDING CONCERNS TO BE DISCUSSED WITH STAFF?
If Yes, please contact Operational Head with further details / YES / NO
ARE THERE ANY MEDICAL ISSUES APS NEED TO BE AWARE OF? / YES / NO
If yes please describe medical condition below:
HAVE YOU COMPLETED THE RISK ASSESSMENT FORM? / YES / NO
HAVE YOU COMPLETED THE BESD FORM? / YES / NO
HAVE YOU GATHERED APPROPRIATE WORK FOR THE PUPIL TO COMPLETE WHILST AT APS? / YES / NO
HAVE YOU INCLUDED THE PUPIL’S APP GRIDS AND IEPS? / YES / NO
HAVE YOU INFORMED THE PARENTS/CARERS THAT YOU ARE MAKING THIS REFERRAL? / YES / NO (if no, please explain why) / IF YES HAVE THE PARENTS AGREED TO THIS PLACEMENT? / YES / NO
SCHOOL
SCHOOL CONTACT
POSITION
EMAIL CONTACT
DURATION OF PLACEMENT:
REQUEST SUBMITTED BY: / PRINT / SIGN / DATE
HEADTEACHER
PLEASE COMPLETE ALL SECTIONS BEFORE SUBMITTING REFERRAL FORM