Education Improvement Service

Request for Specialist Support(Form B)

Please complete one form per pupil. This information will be used at the referral panel so that the most appropriate professional is allocated.

The school needs to keep a copy in the child’s file.

PUPIL INFORMATION

School:

Pupil Name:

Gender: MaleFemale D.O.B: Year Gp:

Looked After Child: Yes/ NoPupil Premium: Yes/No

GRT: Yes/NoHome Language if not English:

NB Where a GRT child has English as an Additional Language (EAL), a referral should be made in first instanceto Multi Lingual Team.

Parent/Carer:

SEN Support Y/NStatement Y/NEHCP Y/N

Has vision been checked? Y/N Please give dates

Hashearing beenchecked? Y/N Please give dates

Other agency/team involvement:

Professional Involved / Agency / Date of report

Relevant medical information:

Inreceipt of SEN High Needs Funding Y/N Band/amount

SCHOOL CONTACT TO DISCUSS REFERRAL:

Name:

Title:

Email/contact details:

What are the desired outcomes of this referral?

Learning Strengths

School Tracking Information

Primary - Copy of child’s SPRINT tracker –(or similar) for at least 1 term

Secondary - Copy of all subject assessment data for at least 1 term

Where KS1, if appropriate, attach tracking for Early Years

Support provided for the pupil by the school

Copy of costed provision map (please use the Stockton format to complete this – it must include 1 full term including the review section)

Other relevant assessments(e.g. Reading and Spelling)

A report from school detailing the current situation ( NC levels/assessments covering 24 months). You should provide a ‘pen picture’ of the child which includes:

  • actions which have been taken to address the child’s difficulties which are not outlined in the above information.
  • details of engagement with parents and their thoughts regarding the future provision for their child.
  • details child’s views regarding their future support and provision.
  • information relating to the child’s home circumstances and any Social Servicesinvolvement (if relevant).
  • reference any provision from Stockton Borough Council’s Local Offer

Referral authorisation and completion signatures
In signing this application you are acknowledging that all essential information is present
Head Teacher / Date
SENCO / Date

Signed parental permission will be required once support has been agreed

Office Use:

Date / Office Sig
Referral complete
Scheduled SLT referral panel date
Outcome
Outcome communicated with school

Education Improvement Service

Education Centre, Junction Road, Norton, Stockton-on-Tees, TS20 1PR

Tel: (01642) 527129

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