Official Sensitive Personal

IN YEAR FAIR ACCESS PANEL REFERRAL FORM

Please submit all completed forms to the email address for your area:

, or

*REFERRALS RECEIVED WITHOUT PARENT/CARER SIGNATURES BY THE DEADLINE WILL NOT BE HEARD AT THE IYFAP MEETING

*REFERRALS MUST BE SCANNED AND EMAILED OR FAXED – WITHOUT PARENTAL SIGNATURE THE REFERRAL WILL BE REJECTED WITH NO EXCEPTIONS

Referrer Details

School: / Completed by:
Date of referral: / Position:

Pupil for Discussion

Name of pupil:
Date of birth:
Address:
Postcode:
Gender:
Ethnicity:
Home Language:
Current Year Group:
UPN:
Free School Meals: / Yes / No
Pupil Premium: / Yes / No
Statement / EHCP: / Yes / No / Date of next Annual Review:
Looked After Child: / Yes / No / If yes, name of Local Authority:
Name and contact details of Social Worker:
CAF/TAC/CIN/CP: / Yes / No / If yes, name and contact details of Co-Ordinator / Social Worker:
Other agencies involved? (please list below with name / organisation / contact details)
E.g.: Youth Offending Service/Educational Psychology/Educational Welfare Officer/Integrated Delivery Team (CAMHS)

Parent/Carer Details

Parent/carer name(s):
Relationship to child:
Home telephone no: / Mobile no:
Address: (if different from child)
Parent/carer name(s):
Relationship to child:
Home telephone no: / Mobile no:
Address: (if different from child)

School Details

All previous schools/settings attended prior to the current setting:(with dates starting with the most recent)
List any previous alternative or specialist provision(with dates starting with the most recent.) This may include referrals to outreach services, PRUs etc

Please list the Fixed Term and Permanent Exclusion history details in chronological order starting with the most recent first:

Date(s) / Length of Fixed Term Exclusion / Primary Reason for Exclusion / Comments

Attendance

% Present / % Late / % Unauthorised Absence / Date Last Attended

Add any additional comments regarding the pupil’s attendance history

(any reasons for poor attendance etc)

Reason For Referral To IYFAP - Representation to support the referral must be made at the IYFAP meeting

Reason for referral:
Pupil’s strengths:
Detail preventative strategies prior to referral:
Triggers:

*UP TO DATE RISK ASSESSMENT MUST BE INCLUDED WITH THE IYFAP REFERRAL

KS2 Data
English
Maths
Science / KS3 Data
English
Maths
Science / Current
Reading SS
Spelling SS
Writing SS
GCSEs Selected and Predicted Grades:(Year 10 and 11 only)
Parent/CarerUnderstands & Supports the IYFAP Referral For Discussion / Yes / No
Parent / Carer Signature
Please read: By signing this document you are giving your permission for the information contained in this referral form to be shared with other schools in the local area and agencies who attend the IYFAP. The agencies who attend include Early Help, Youth Offending Service, Educational Psychology, Social Care and Child and Adolescent Mental Health Services.

This information has been provided for the sole use of the In Year Fair Access Panel. If printing, please destroy this information confidentially. This information must not be shared with any other parties in compliance with the Data Protection Act 1998.

IYFAP Referral January 2016

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