Education Welfare Service Referral Form

Education Welfare Service Referral Form

The information contained in this referral form may be used in any legal action under the Education Act 1996 relating to non-attendance of a registered pupil at the school

Complete all sections fully. Incomplete forms will be rejected. Strike through where marked * as appropriate.

REFERRING SCHOOL
School name and address:
Referrer’s name: Position:
Phone number: Fax number:
Email/ Anycomms mailbox (Head/Senco/Admin):
PUPIL DETAILS
Full Name: / Home Address:
Date of Birth:
Year Group:
Siblings(please include full name and school):
If none known please indicate:
PARENTS/ GUARDIANS DETAILS
First Names / *Mr/Mrs/Ms/Miss / First Names / *Mr/Mrs/Ms/Miss
Surname / Surname
Date of Birth
(if known) / Date of Birth
(if known)
Address
(if different to above) / Address
(if different to above)
Contact Telephone Number/s / Home:
Mobile: / Contact Telephone Number/s / Home:
Mobile:
Relationship to Child / Relationship to Child
Translation/ Interpreter Needed / *Y/N
If yes, what language: / Translation/ Interpreter Needed / *Y/N
If yes, what language:
SIGNIFICANT OTHERS (Living in or out of the Pupil’s home)
Full Name / Relationship to Pupil / Contact Details
(Address & Telephone Number)
PUPIL’S ATTENDANCE INFORMATION
Attendance Data
Current Attendance Percentage:
Total Number of Unauthorised Absences:
Total Number of Authorised Absences:
KNOWN ISSUES AFFECTING PUPIL’S ATTENDANCE (for example: health, emotional health and wellbeing, behavioural, identity issues, self-esteem, confidence, family and social relationships)
PARENTS/GUARDIANS PERSPECTIVE (regarding issues of absence)
PUPIL’S PERSPECTIVE (regarding issues of absence)
ANY KNOWN RISKS (Domestic violence/alcohol and substance misuse etc)
PROFESSIONAL INVOLVEMENT WITH FAMILY
If marked, state name of contact and contact details and nature of involvement
Social Worker
Health Practitioner
EWO
EP
SEND
Parenting Practitioner
YOS
Family Matters
Other
SCHOOL INTERVENTION/ACTIONS TAKEN TO IMPROVE ATTENDANCE
Please record actions taken by the school to address issues of poor/non- attendance. Please attach all letters, minutes of meetings and all other relevant evidence to this referral

NB: Please ensure that the parents/carers are notified of this referral, in writing. Please attach a copy of this letter to the referral form. Please ensure you have discussed this referral with the Education Welfare Officer before submitting.

FOR EDUCATION WELFARE USE ONLY

Date Referral Received
Referral Accepted
Date of First Contact

Signed by Education Welfare Officer: ………………………………………………………………………....

Date: ………………………………………………………………………………………………………………....

Signed by Senior Education Welfare Officer: ……………………………………………………………….

Date: …………………………………………………………………………………………………………………

Date drafted September 2017 Date to be reviewed August2018