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Online Referral Form

Student Details


School Details


Name of Parents/Carers

Confirmation of Students Referral

Parental permission has been obtained for this referral?(required)

Dinner Arrangements

If free school meals, then please note that the base school will be invoiced for each day when the child is here over the dinner time.

Other Agencies

Please attach any relevant reports (up to 3 - limit 5MB, if additional files are larger than permitted, please send them to us via email.):

Attendance Data & School History

Details of Exclusion

Please provide dates and details:

Concerns, difficulties and progress

What interventions do you hope for from this referral?

Please attach reports about medical conditions, social care involvement, CAF, family concerns, PSPS Completed, BSPS, IEPS, (last two), copies of last school report.

Conduct Behaviour

1. Behaves disrespectfully towards teacher.
E.g. Is impolite, disrupts, intimidates, deliberately annoys, verbally aggressive.

2. Lacks respect for other pupils.
E.g. Name calling, swearing, psychological intimidation
bullying, physically intimidating.

3. Is verbally abusive.
E.g. Racial/gender/religious/learning disability abuse.

4. Seeks attention inappropriately.
E.g. Disrupts/distracts/interferes with others, misuses equipment.

5. Is physically aggressive.
E.g. Fights, is spiteful, strikes out in temper.

6. Disrespects property.
E.g. Does not value/look after property, damages/destroys,

7. Uses sexually inappropriate behaviour
E.g. Touching, language, intimidation.

E.g. Truants from lessons, absent from classes.

9. Offending behaviour.

E.g. Known to have been involved in offending behaviour in or out of school.

10. Involvement with weapons.
E.g. Is known to have carried/misused weapons.

Emotional Behaviour

11. Lacks empathy.
E.g. Lacks tolerance, sympathy, inconsiderate

12. Lacks social awareness.
E.g. Does not interact appropriately, is a loner, isolated.

13. Seems unhappy.
E.g. Rarely laughs, smiles, is tearful, seems anxious or depressed.

14. Lacks confidence.
Eg. Has low self esteem, fears failure, is shy, afraid of new things.

15. Is emotionally unstable, lacks self control
E.g. Moods unstable, mood swings, impatient, easily flustered, touchy.

16. Self harm.
E.g. Shows signs of self harm, either physical or emotional

17. Substance abuse.
E.g. Known incidences of drug, alcohol misuse.

Learning Behaviour

18. Is inattentive.
E.g. Little interest in school work, easily distracted, does not remain on task, poor concentration, poor motivation, easily frustrated.

19. Poor learning organisation.
E.g. Does not work systematically, is not organised,works at an inappropriate pace, does not have equipment.

20. Poor communicator.
E.g. Speech incoherent, does not think before answering, Limited communication skills, reluctant to speak.

21. Does not work efficiently in a group.
E.g. Does not take part/contribute in groups, does not workcollaboratively, does not take part in discussions.

22. Does not seek help when necessary.
E.g. Does not approach teachers for help, refused the taskin the face of difficulty, cannot cope with challenges.

23. Behaviour difficulties in practical lessons.
E.g. Behaviour deteriorates in practical subjects.

24. Has difficulty in social times
E.g. Behaviour of concern in break/lunch times, before/after school.

25. Behaviour of concern on trips.
E.g. Concerning behaviour on trips out of school.