St Thomas’s Centre

REFERRAL PROCESS TO ST THOMAS’S

Pupil Name:
School:
DOB:
Year Group:
Current SEN Status / SEN Support / EHCP / Statement / IPRA (please circle)
UPN: / FSM: Yes / No (please circle)
Does this pupil receive Pupil Premium monies: Yes / No (please circle)

Attainment Levels

KS1 Results or Current / KS2 Results or Current / KS3 Results or Current / End of Key Stage predicted result
English / Reading
Writing / Reading
Writing
SPAG
Maths
Science
IT

Early year’s profile

KS1 phonics screening results ______

Targets

Primary

Please write smart target for next 6 weeks
Reading
Writing
Maths
Behaviour

Secondary

Please write smart target for next 6 weeks
English
Maths
Science
IT
Behaviour

Requested placement

Type of placement / Please tick
FIXED TERM PLACEMENT AT £75 PER DAY (15 DAYS MAX)
PUPIL REQUIRING OUTREACH SUPPORT – PRIMARY ONLY
PUPIL WHO WOULD RECEIVE A PERM EXCLUSION AS A RESULT OF A ONE OFF INCIDENT
PUPIL WHO DUE TO PERSISTENT DISRUPTIVE BEHAVIOUR IS AT RISK OF PERMANENT EXCLUSION
NON ATTENDANCE
SEN STUDENTS IN RECIEPT OF STATEMENT OR IPRA AND MAINSTREAM SCHOOL CANNOT MEET NEEDS OF PUPIL
SUPPORT WITH A STAT. ASSESMENT
SAFEGUARDING CONCERNS
BREAKDOWN OF A MANAGED MOVE
PENDING A PLACE AT A SPECIAL SCHOOL
PREGNANT SCHOOLGIRL
MEDICAL
SPECIFIC BAIL / YOT CONDITIONS
ALTERNATIVE KS4 PACKAGE IN CONJUNCTION WITH BLACKBURN COLLEGE

Agency involvement

Agency / Service / Dates of Involvement / Named Contact / Minutes of last meeting and attached.
CAMHS
Children’s Services Social Care
Communicare/Consultant / Midwife
Complex Needs Team
Educational Psychologist
Education Welfare Service
Inclusion Support Service
Regulatory Services
School
Youth Offending Team
Voluntary sector
Other:

Is the pupil on the Child Protection Register? Yes / No

Is the pupil “in Public Care” by a Local Authority? Yes / No

Name of Authority ______

Does the pupil have a CAF? Yes / No

Who is leading the CAF ? ______

Agreed by parent Yes / No (please circle)

Please ensure the following are completed and attached (please circle)

Risk assessment Yes / No

Most recent PSP / IEP / IBP Yes / No

Most recent EP report Yes / No

SIMS contact details attached Yes / No

SIMS Attendance report attached Yes / No

School Senior Lead Contact ______