The Acorns School Request for Intervention Form

Important please note:

  • All students in need of additional support or advice should have a CAF in place
  • Please attach additional documents e.g. CAF, attainment data, attendance data etc. requested
  • Medical Referrals must have consultant or CAMHS professional back-up. GP back-up is not sufficient.
  • Ensure completion of the InterventionAgreement Form
  • Please entitle the referral email with RFI: student name & school.
  • Return to (please do not email to a named person in the school)
  • We will get back to you within five working days of receipt of the completed application.

Please note that incomplete referrals will not be processed until all relevant information is received

Key details:

Name of student: / Referral date: / Age:
School: / DOB:
Gender: / Year Group / Ethnicity
UPN: / ULN: / PPG:
Attendance: / Last Term: % / Last Academic Year: % / Ever 6 and date:
CLA:
Name of person making the referral: / Role:
Contact numbers: / Email:
Name of main carer(s) / Relationship / Home Address / Contact numbers:
Home:
Mobile:
Emergency:
Details of additional family members at home: / Ages:
Are parents/carers aware of the referral? / Y or N / Have they agreed to support the request? / Y or N
Is the school nurse aware of this request / Y or N / Name of the school nurse

Intervention requested:

Behaviour
Medical

Behaviour:

Number of incidents in 6 weeks prior to referral / Number of exclusions in last 12 months
Nature of incidents/exclusion code(s)

Medical:

Name of Doctor
Contact Number
Reason for Medical Referral (Please provide supporting letter from consultant):

CAF Details:

Name of CAF lead / Date(s) CAF Submitted
CAF Number
Last CP / CIN review date

Please attach CAF

Professionals involved

Name of Agency/Support / Name of Professional / E-mail / Contact Number
CSC
CAMHS
YOT
Other

Educational Information:

SEN / IEP / PEP etc. information:

SENCO consulted? / SENCO’s name
SEN Status / SEN Start date
PEP in place? / Support Plan /Pupil Passport
EP involvement? / Date(s) EP seen
Name of EP / Outcomes EP involvement

Please attach EP Report and EHC Plan

Assessment Information:

Current progress attainment data: (levels or standards working at reported to parents/ within school tracking systems
Maths:
English
Science:

WRAT/Standardised Scores:

Score Date

Reading
Comprehension
Spelling
Numeracy

CAT Test Scores: Date

Verbal
Non-verbal
Quantitative
Average

End of Key Stage Attainment:

Achieved Predicted

KS2 Maths / KS3 Maths
KS2 English / KS3 English
KS2 Science / KS3 Science

KS4 Exam/Course Entry Details (where applicable):

Unique Candidate Examination Number:
Course Name / Predicted KS4 attainment / Exam Board / UCI Number / Key teacher’s name

EXAM ACCESS ARRANGEMENTS APPROVED? Yes / No If Yes please indicate support to be provided:

Key Issues for the Pupil – Please mark with a X all those relevant

School based

Accessing off site provision / Acute behavioural issues / Many historical school moves
Attendance Issues / SEN support / EHC Plan / Issues at primary school
Punctuality issues / Disaffected / Managed moves tried
Regular exclusions / Seen E.P. / E.A.L.
Disruptive behaviour / Progress below expectations / Gifted and Talented register
Literacy Concerns / Numeracy Concerns

Personal

Child looked after / Perpetrator of bullying / Trauma experience
Anger Management Issues / Victim of bullying / Currently involved with YOT
Withdrawn and disengaged / Alcohol misuse / Historically a young offender
Physical Issues / Cannabis misuse / Sexually vulnerable
Mental Health Issues / Other drug misuse / Sexually inappropriate
Medical Issues / Self- harm issues

Family and Home

Absent Parent / Parental mental health issues / Teenage parent
Social Care CIN Plan / Domestic abuse / Parent in prison
Social Care CP Plan / Adult substance misuse / Bereavement
External Agencies involved / Young carer / Negative peer group
Parental physical illness / Housing issues / Siblings with needs
Safeguarding Concerns / Risk Assessment required

Please provide further information for all those which are ticked and include any other relevant information, including any risks regarding home visits.

Intervention Strategies already used

Strategy / Date / Detail
Reduced timetable
Family liaison
Managed Move
Alternative provision
Other -

Key Documents required (where applicable) office use only

Document / Attached / Received
CAF
Attendance certificate - current academic year
E.P. Report
SEN reports
EHC Plan
Behaviour log
Exclusion log
CP reports (to be delivered)
PEP reports
Support Plan
Last school report
Primary school transition information
Supporting letter from consultant (Medical)

Next steps:

The application will be processed

Eitheryou will be contacted to arrange a TAF oryou will be advised the application will be placed on a waiting list for available places

Acorns will attend the TAF and agree with all present a place and admissions date a likely start date.

The Intervention agreement will be signed by host school.

Parents/ Carers and Student will attend admissions at The Acorns School (If parents/ carers do not attend the place will not be allocated

Student will commence at Acorns the day after admissions providing all information has been received by host school.

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