Referral Form

Child’s Name: / School
D.O.B: / Gender:
Ethnicity: / Year Group:
Dates of Fixed Term
Exclusions (last 12 months)
SEN Status: / School Support Statutory Assessment
What are your 3 biggest concerns for this child/family?
Impact
Only a little / Quite a lot / A great deal
Only a little / Quite a lot / A great deal
Only a little / Quite a lot / A great deal

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Attainment

Current Teacher Assessment / Date
Reading
Writing
Numeracy

Reading & Spelling Ages

Read/Spelling Age / @ / Chronological Age / Date / Test used
Reading / @
Spelling / @
Please list the interventions that school have put in place to support the referred child’s Special Educational Needs:

Other Services

Please record the names of services that have supported the child or family and tick to indicate whether this was a previous involvement or is a current one

Name of Service / Previously involved / Currently Involved / Contact Person

Please circle the highest level of Social Care intervention that the child has received:

None / Child in Need / Child Protection / Looked After Child
Please state the interventions that you think would be most effective in supporting the child you are referring:

Additional Information Checklist

Please also include the following information:

A copy (please retain originals) of all SEN and Pastoral information, including reports from professionals
Provision map of child’s in school support
1 week of EPC On Task Record sheet (attached)
Evidence of engagement with parent/carer to support child’s difficulties
Completed Behaviour for Learning questionnaires (Parent & Teacher copies attached)

Please also print the following information from SIMS / school database:

Family address and contact numbers

UPN

FSM entitlement

Attendance

GP address

Parent/carers views

Please describe any concerns you may have for your child at home and at school. Please also describe what help, if any, you think may help your child, family or the school.

I agree to this referral to the Primary Behaviour Service and that they may contact other agencies to request and share information

Signed:Date:

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Daily Tick Sheet for On Task Behaviour

8:50 / 8:55 / 9:00 / 9:05 / 9:10 / 9:15 / 9:20 / 9:25 / 9:30 / 9:35 / 9:40 / 9:45 / 9:50 / 9:55 / 10:00 / 10:05 / 10:10 / 10:15 / 10:20 / 10:25 / 10:30 / 10:35 / 10:40 / 10:45 / 10:50 / 10:55 / 11:00
11:05 / 11:10 / 11:15 / 11:20 / 11:25 / 11:30 / 11:35 / 11:40 / 11:45 / 11:50 / 11:55 / 12:00 / 12:05 / 12:10 / 12:15 / 12:20 / 12:25 / 12:30 / 12:35 / 12:40 / 12:45 / 12:50 / 12:55 / 1:00 / 1:05 / 1:10 / 1:15
1:20 / 1:25 / 1:30 / 1:35 / 1:40 / 1:45 / 1:50 / 1:55 / 2:00 / 2:05 / 2:10 / 2:15 / 2:20 / 2:25 / 2:30 / 2:35 / 2:40 / 2:45 / 2:50 / 2:55 / 3:00 / 3:05 / 3:10 / 3:15 / 3:20 / 3:25 / 3:30

Please tick when child is on task or put a dot if they are not. Please also annotate with comments.

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Behaviour for Learning Rating Scale (Parent)

A child’s ability to learn within a classroom environment will be influenced by a wide range of factors. Please read the following statements and respond to them byconsidering your child’s skills and behaviours in the last two month period. Please mark the box to indicate your response to each statement.

Never / Sometimes / Often / Always / Don’t
Know
Managing feelings and behaviours
1. My child has difficulty calming themselves down when they feel frustrated or angry at school.
2. My child copes well in difficult situations at school.
3. My child can stop and think before acting at school.
4. My child demonstrates challenging behaviour in class.
5. My child is physically aggressive with other children.
6. My child experiences excessive anxiety at school.
7. My child appears sad and/or withdrawn at school.
Motivation and educational attainment
8. My child is able to focus on their school work at a level appropriate for their age.
9. My child will persevere with their work even when they find the work that has been set for them difficult.
10. My child enjoys learning at school.
11. My child generally works hard at school.
12. My child achieves to the best of their ability at school.
Social Skills
13. My child is able to listen, understand and respond appropriately to adults (e.g. teachers) at school.
14. My child is able to successfully resolve conflict with other children.
15. My child is able to work effectively in a group of other children.
16. My child is able to make and sustain friendships at school.
Attendance
17. My child is absent from school due to sickness.
18. My child truants (skips school).
19. My child is at risk of formal exclusion from school.
20. My child has been formally excluded from school.

Please turn over; there are a few more questions on the other side

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Never / Sometimes / Often / Always / Don’t
Know
Home-school relationship
21. My child is well supported in their learning by their family/caregivers.
22. My child is well supported in their learning by their school.
23. My child school and family/caregivers work together to support my child.
24. Parents/carers and teachers are in agreement in regard to my child’s needs.
25. Parents/carers and teachers are in agreement on how to meet my child’s needs.

Please also fill in the following information:

Date of completion:

Your name:

Your child’s name:

If you have any further comments that you would like to make in response to any of the questions that we have asked you, then please write them here (continue on a separate piece of paper if necessary)

Behaviour for Learning Rating Scale (School)

A child’s ability to learn within a classroom environment will be influenced by a wide range of factors. Please read the following statements and respond to them byconsidering your child’s skills and behaviours in the last two month period. Please mark the box to indicate your response to each statement.

Never / Sometimes / Often / Always
Managing feelings and behaviours
1. My pupil has difficulty calming themselves down when they feel frustrated or angry at school.
2. My pupil copes well in difficult situations at school.
3. My pupil can stop and think before acting at school.
4. My pupil demonstrates challenging behaviour in class.
5. My pupil is physically aggressive with other children.
6. My pupil experiences excessive anxiety at school.
7. My pupil appears sad and/or withdrawn at school.
Motivation and educational attainment
8. My pupil is able to focus on their school work at a level appropriate for their age.
9. My pupil will persevere with their work even when they find the work that has been set for them difficult.
10. My pupil enjoys learning at school.
11. My pupil generally works hard at school.
12. My pupil achieves to the best of their ability at school.
Social Skills
13. My pupil is able to listen, understand and respond appropriately to adults (e.g. teachers) at school.
14. My pupil is able to successfully resolve conflict with other children.
15. My pupil is able to work effectively in a group of other children.
16. My pupil is able to make and sustain friendships at school.
Attendance
17. My pupil is absent from school due to sickness.
18. My pupil truants (skips school).
19. My pupil is at risk of formal exclusion from school.
20. My pupil has been formally excluded from school.

Please turn over; there are a few more questions on the other side

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Never / Sometimes / Often / Always
Home-school relationship
21. My pupil is well supported in their learning by their family/caregivers.
22. My pupil is well supported in their learning by their school.
23. My pupil school and family/caregivers work together to support my child.
24. Parents/carers and teachers are in agreement in regard to my pupil’s needs.
25. Parents/carers and teachers are in agreement on how to meet my pupil’s needs.

Please also fill in the following information:

Date of completion:

Your name:

Your child’s name:

If you have any further comments that you would like to make in response to any of the questions that we have asked you, then please write them here (continue on a separate piece of paper if necessary)

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