Redbridge e-forms Medical Referral to the Redbridge Medical and Inclusion Service Step 1 of 14 7% Medical Referral to the Redbridge Medical and Inclusion Service Please note that medical tuition is not guaranteed. This should be made clear to parents/carers. By making a referral to the Redbridge Medical and Inclusion Service, you confirm that you agree to the following mandatory requirements: School is responsible for curriculum and work to be provided on a regular basis. Review meetings should be arranged and held regularly, at least once a term, by the school. Key School Contact to provide school work Key School Contact to arrange review meetings Key School Contact Details Key School Contact Name(Required)Key School Contact Email(Required) Key School Contact Telephone(Required)Referring SchoolKey School Contact Role Declaration Has the referral been discussed and agreed with parents/carer? Yes No Has this referral been discussed and agreed with pupil? Yes No Up to date Individual Health Care Plan(Required) Yes No Please attach document(Required)Max. file size: 10 MB. If evidence is too large to attach email directly to BehaviourAndInclusion@redbridge.gov.uk. Confirm the date of pupil’s latest Individual Health Care Plan(Required) DD slash MM slash YYYY Attendance Certificate(Required) Yes No Please attach document(Required)Max. file size: 10 MB. If evidence is too large to attach email directly to BehaviourAndInclusion@redbridge.gov.uk. Attendance %No. of unauthorised attendancesCurrent medical evidence from Specialist or Consultant(Required) Yes No Please attach document(Required)Max. file size: 10 MB. If evidence is too large to attach email directly to BehaviourAndInclusion@redbridge.gov.uk. Type of service requestedType of service requested(Required) 1:1 Tuition AV1 Robot Location of TuitionExpected Loan Period: Start date DD slash MM slash YYYY Expected Loan Period: End date DD slash MM slash YYYY Pupil's DetailsName(Required)UPNUCIULNGender(Required) Male Female Year Group(Required)Date of Birth(Required) DD slash MM slash YYYY Child Looked After ? Yes No Do you live in Redbridge ? Yes No AddressFind addressSelected address AddressEthnicityPlease select ethnicityWBRI - White BritishWIRI - White IrishWIRT - Traveler of Irish heritageWOTH - Any other white backgroundWROM - Gypsy/RomaMWBC - White and Black CarribeanMWBA - White and Black AfricanMWAS - White and AsianMOTH - Any other Mixed BackgroundAIND - IndianAPKN - PakistaniABAN - BangladeshiAOTH - Any other Asian backgroundBCRB - Black CaribbeanBAFR - Black AfricanBOTH - Any other black backgroundCHNE - ChineseOOTH - Any other ethnic groupREFU - RefusedNOBT - Information not yet obtainedCountry of BirthNationalityPupil Premium Yes No Armed Forces Family Yes No Free School Meals Yes No CAF Yes No Child Protection Yes No Child in Need Yes No SENUntitled(Required) N - No SEN K - School SEN Support Q - under statutory assessment E - EHCP(please attach) Please attach EHCP document(Required)Accepted file types: jpg, rtf, pdf, docx, Max. file size: 10 MB. Parent/Carer DetailsParent Name (1)Parent Name (2)Person(s) with parental responsibility(Required)Family details (child's numerical position in the family): i.e. middle child, number 2.Home telephone detailsHome Telephone numberPlease confirm who this telephone number belongs to Add RemoveWork telephone detailsWork Telephone numberPlease confirm who this telephone number belongs to Add RemoveMobile telephone detailsMobile Telephone numberPlease confirm who this telephone number belongs to Add RemoveEmergency number details(Required)Emergency Telephone numberPlease confirm who this telephone number belongs to Add RemoveLanguage spoken at homeInterpreter required Yes No Services Working with pupil Services working with the pupil Intervention/Agency Contact Name Telephone Number Email Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Reason for referralPlease explain why this pupil is being referred to the Redbridge Medical and Inclusion Service.(Required) Medical Information - Mandatory for consideration Is the pupil currently an inpatient?(Required) Yes No Has the pupil had a hospital admission recently?(Required) Yes No Is there a letter from a specialist or consultant (not GP) supporting a Medical and Inclusion referral as part of the discharge plan?(Required) Yes No Is the pupil’s absence expected to continue for more than 15 school days, either in one absence or over the course of the school year?(Required) Yes No Please explain the action the school has taken to provide education for this pupil and clarify why the school is not able to make suitable provision from its own resources.(Required) Fixed Term Exclusions and SuspensionsFixed Term Exclusions and Suspensions Date Reason No. of ½ school days lost Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Academic DetailsUpload pupil's most recent school report(Required)Max. file size: 10 MB. Upload pupil's latest levels(Required)Max. file size: 10 MB. Risk assessmentHas a risk assessment previously been conducted?(Required) Yes No Upload most recent risk assessment(Required)Max. file size: 10 MB. Summary {all_fields}