Forms home Single point of access referral form for education support Step 1 of 12 8% Evidence of parent / carer permission must be provided with this referral. At least one contact number should be supplied before we can accept the referral. Section 1 - person making the referral / requestFirst name* Last name* Job title* Email* School / setting* Department* Address* Address Line 1 Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Are you referring only for training?* Yes No Section 2 - child / young person’s detailsStudent’s first name* Student’s last name* Gender* Female Male To be specified Please specify Date of birth* Address* Address Line 1 Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Family email* Home telephone Parent’s / carer’s mobile Young person’s mobile number (if over 16yrs) Does child / young person receive Pupil premium DLA/ PIP Nursery / school / college* School year* Attending*Choose an itemFull timePart timeNot in schoolNever been to schoolAttendance at another settingOtherIf part time*1/2 days sessionsless than 1/2 daysLanguage Interpreter required Yes No Religion EthnicityBangladeshiIndianPakistanAsian otherBlack AfricanBlack CaribbeanBlack otherChineseMixed White/ AsianMixed White/ Black AfricanMixed White/ Black CaribbeanMixed otherWhite BritishWhite IrishGypsy/ RomaIrish TravellerWhite otherOtherUnknownIf other Ethnicity* Nationality NHS number (where known) GP name Student’s Level of support EHCP School SEND support No additional support LAC If EHCP, please add the date it was last reviewed* Safeguarding* CAF CIN CP Plan Neither Date moved into Redbridge Previous local education authority Key medical needs School health care plan Yes No Please uploadAccepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.Any other information Section 3 - parent's / carer’s detailsWho has parental responsibility?* Parent’s / carer’s full name* Address* Address Line 1 Address Line 2 City AberdeenshireAngus/ForfarshireArgyllshireAyrshireBanffshireBedfordshireBerkshireBerwickshireBlaenau GwentBridgendBuckinghamshireButeshireCaerphillyCaithnessCambridgeshireCardiffCarmarthenshireCeredigionCheshireClackmannanshireConwyCornwallCromartyshireCumberlandDenbighshireDerbyshireDevonDorsetDumfriesshireDunbartonshire/DumbartonshireDurhamEast Lothian/HaddingtonshireEssexFifeFlintshireGloucestershireGwyneddHampshireHerefordshireHertfordshireHuntingdonshireInverness-shireIsle of AngleseyKentKincardineshireKinross-shireKirkcudbrightshireLanarkshireLancashireLeicestershireLincolnshireLondonMerthyr TydfilMiddlesexMidlothian/EdinburghshireMonmouthshireMorayshireNairnshireNeath Port TalbotNewportNorfolkNorthamptonshireNorthumberlandNottinghamshireOrkneyOxfordshirePeeblesshirePembrokeshirePerthshirePowysRenfrewshireRhondda Cynon TaffRoss-shireRoxburghshireRutlandSelkirkshireShetlandShropshireSomersetStaffordshireStirlingshireSuffolkSurreySussexSutherlandSwanseaTorfaenVale of GlamorganWarwickshireWest Lothian/LinlithgowshireWestmorlandWigtownshireWiltshireWorcestershireWrexhamYorkshire County Postcode Interpreter required Yes No Preferred method of contact* Phone Email Telephone* Email* Preferred contact time Morning Afternoon Either Section 4 - other services / professionals involved (current and past). Please select all services involved in each sectionSocial care CWDT Family support worker Social worker Adult Social Work Team Early years Early years advisory service Health visitor Other Please specify* Outreach Historic support from a Redbridge Outreach Service eg Hatton, Little Heath, Churchfields etc Please specify* Other Education services Behaviour and Inclusion (B&I) Educational Psychologist (EP) Education Welfare Officer (EWO) Home Tuition Other Please specify* Health Community Nursing Team Continence Team EWMHS (previously known as CAMHS) Feeding SALT Occupational Therapist Paediatrician Physiotherapist Referral made to CDC (Child Development Centre) SALT Other Please specify* Hospital Contact name and details at the hospitalHospital Contact name and details at the hospitalAdditional hospital informationOther Youth Offending Team Fusion YP - Substance Misuse Service Social Care Connexions Other Please specify Audiology Clinic Contact name and details at the hospitalPlease list all involvement from outside professionals in the past 12 months, and the outcome of their involvement / recommendations Outcome Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Has this student moved into your setting in the last term? Yes No Is this student due to move through a significant transition point in July? eg Reception to Yr 1, End of KS 2 or End of KS 4 Would you like support with this?* Yes No Section 5 - reason for referralReason for referral*Choose an itemCSW (Communication Support Worker)EHCP – advice and support implementing strategies /outcomes outlined in an EHCPHabilitation Officer supportICT assessment /supportInitial AssessmentParent/Carer SupportPost-traumatic stress / AnxietyReview of past work and strategiesSupport for a child at risk of exclusionTraining and advice for a specific studentTransitionTransition*Choose an itemPhased transferSchool moveTransition into schoolPlease identify the primary area of need*Choose an itemAttention and listeningAuditory processing disorderAutistic spectrumCognition and learningComplex needsExpressive languageGlobal learning difficultiesHearingMedical needsMentoringMotorPhysical disability/ physical access to learningReceptive languageSEMHSocial communicationSPLD ie memory, organisationVisionAdditional needs Attention and Listening Auditory Processing Disorder Autism Spectrum Cognition and Learning Complex Needs Expressive Language Global Learning Difficulties Hearing Medical Needs Motor Multi- Sensory (deaf, blind) Physical Disability / Physical Access to learning Receptive Language SEMH Social Communication SPLD ie Memory, organisation Vision Any other information. Including any formal diagnosis (please evidence where possible)Evidence (optional) Drop files here or Select files Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB. Section 6 - developmental history (where known)Key developmental milestones. eg began speaking, first steps, independently sitting etcDate of last eye test Outcome of last eye test Date of last hearing test Outcome of last hearing test Section 7 - assessment detailsPlease list current learning levels. These must include core subject areas – English and Maths (Compulsory) Learning level Core subject area Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Interventions / strategies past and present including outcomes of these (assess, plan, do and review). Please indicate all school support, external interventions and specialist provision*Please attach provision map / timetable and any other individual assessment or school data if this is easier to summarize* Drop files here or Select files Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB. Section 8 - parental concerns and relevant family historyParental concerns / views on the referralAdditional information the family would like to be sharedPlease upload signed Parental Consent form*Max. file size: 10 MB.Referrals will no be processed without this consent being attached Section 9 - child / young person’s viewsChild / young person’s views on the referral(Child / young person’s views on the referral where appropriate) Section 10 - permissionsPlease tick to confirm you have read and understood the following involvement. I understand the SENCO / other professional will request support / advice/ assessment from S.E.A.T.S.S. Following a referral, a member of the Team may visit your son / daughter in pre-school / school / college.Consent* By checking this box you confirm that you have read, understood and agree to the involvementDuring this visit I understand and I give permission for a member of the Team to Select All Visit the school / setting Obtain data. Medical information (where relevant), talk to key members of staff to ascertain a full picture Observe / work directly with your child The personal information we gather is only used by us to help your child at school and at home. It will only be shared with you, the school and directly with relevant professionals. We use the information gathered to write reports, make suggestions for the school (if any) and you. The information is stored on a secure internal database. By default, we retain it until your child is 25 years old. You may request a copy of all information we retain at any time and ask for it to be deleted or amended Work with my child in class or outside class if the assessment requires it Take photos / videos of my child during the assessment and the photos will be added to the report. Any unused photos will be destroyed at the time of report writing I agree to share hospital information (if relevant) I understand that as my Child moves through Education, their needs or the focus of support may change, and they may receive support from additional teams or have support reduced/removed if it is no longer required. Full name* Section 11 - trainingPlease tick all areas you are interested in Whole school CPD - INSET day Twilight CPD sessions In school CPD sessions LSA training Parent’s sessions Please select Primary Secondary Other Areas of training currently offered – please select which you require 5P Access arrangements AET (accredited training) App’s to support a range of curriculum areas/ needs Autism Back care of parents Back care of staff Behaviour / 5P scale BSL- family training Can’t write/ won’t write Class disability awareness session Coaching and mentoring Disability awareness assemblies Communication Developing conversation / communication skills Developing tray independence Down’s syndrome Engagement profile Fine and gross motor training including happy hands, healthy hands Hearing Impairment training Incredible 5 point scale Motor and life skills – readiness for school (nursery / pre-school) Moving and handling (accredited training) Neurological profile and the impact on the learner Numicon PEEP’s and risk assessments PD net level training PD Ambassador POST AET Bespoke Staff Training – add this under the AET-Accredited Training Pre- stage standards Precision teaching Revision strategies and techniques Quality First Teaching /Adaptive Teaching Sensory learning Social stories Specific condition eg dystrophy, cerebral palsy, spina bifida Steps to being a writer – pre writing, alternatives forms of recording SEMH Project Social Groups SPLD Project Strategies for Inclusion Study skills / memory (secondary) Talkabout Teenage talkabout Using ICT to support literacy and dyslexia Using ICT to support non-verbal students Using ICT to support visual Impairment Visual impairment training Zones of Regulation Other training not listed above, please specify Do you have a specific date MM slash DD slash YYYY Do you have specific time : Hours Minutes AM PM AM/PM Communication and Language Intensive interaction Narrative approach Top tips when working with students who have expressive language difficulties Speech and Language strategies for the Class teacher Makaton taster session – introductory session teaching key and useful words BSL- introductory session teaching key and useful words How to use Colourful Semantics in the classroom Supporting Students who have speech and language programmes in the classroom Autistic Spectrum / Social Communication Strategies to support attention and listening Now and next boards Tray work The value of visuals Visual strategies Comic strip Conversations AET – Accredited Training Focus, attention and behaviour 5 Point scale Supporting challenging behaviour Neurological profile and learning Anxiety and coping skills Anger management Zones of regulation ADHD Skill of active listening Positive Handling – Accredited Course Circle of friends Social Stories Sensory Sensory circuits Sensory profile and how to support sensory needs in a classroom Supporting a deaf student in the classroom Supporting a student with a visual impairment Physical Specific physical disability eg Epilepsy, Cerebral Palsy, Muscular Dystrophy Specific medical conditions and how they impact on access to learning PEEPS Moving and Positioning – Accredited Course Can’t write/ won’t write Fine motor skills Gross motor skills Adaptive PE PE Ambassador scheme Back care for staff /parents/ carers Please specify physical disability eg Epilepsy, Cerebral Palsy, Muscular Dystrophy* Please state Specific medical conditions and how they impact on access to learning* ICT Apps and software to support fine motor Apps and software to support speech and language Apps and software to support writing Apps and software to support spelling Apps and Software to support organisation and study skills App’s and software to support non- verbal students communicate Hard and Software – Visual Impairment Equipment used to support students who are deaf Personal understanding of deafness Literacy First steps to reading Supporting the reluctant reader/ writer Increasing learner engagement with reading and writing Writing support ideas Other Precision Teaching Study skills Organisation skills -KS 2, KS3, KS 4 SENCO coaching and mentoring Class disability sessions Downs Syndrome Engagement Model Pre Key Stage Standards Numicon Inclusive Classroom Talkabout/ Teenage Talkabout Would you prefer to have a bespoke session created to meet your specific needs? If yes, please outline key areas you would like to cover, and we will book a time to discuss options and create a bespoke offer for your settings Please outline key areas that you would like to be covered {all_fields:nohidden}
