Student Details Date of Birth L.A.C YesNo Date of Entry School Details Address Name of Parents/Carers Confirmation of Students Referral Parental permission has been obtained for this referral?(required) YesNo 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. Free School DinnersPaid School DinnersPacked Lunch Other Agencies Are there any other agencies involved with the pupil? (E.G. EWO/BSS/YOT/EPS/CAMH/SSD/LAC) Please include names and details on involvement. 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 FTEXPEX Please provide dates and details: Concerns, difficulties and progress What interventions do you hope for from this referral? Outreach SupportRespite in HouseManaged MoveAlternative ProvisionIntegrated SupportMedical Request Other relevant additonal information: Please attach reports about medical conditions, social care involvement, CAF, family concerns, PSPS Completed, BSPS, IEPS, (last two), copies of last school report. Is the pupil taking any medication? If so what? Any Allergies? Conduct Behaviour 1. Behaves disrespectfully towards teacher. E.g. Is impolite, disrupts, intimidates, deliberately annoys, verbally aggressive. NeverRarelySometimesUsuallyFrequentlyConstantly 2. Lacks respect for other pupils. E.g. Name calling, swearing, psychological intimidation bullying, physically intimidating. NeverRarelySometimesUsuallyFrequentlyConstantly 3. Is verbally abusive. E.g. Racial/gender/religious/learning disability abuse. NeverRarelySometimesUsuallyFrequentlyConstantly 4. Seeks attention inappropriately. E.g. Disrupts/distracts/interferes with others, misuses equipment. NeverRarelySometimesUsuallyFrequentlyConstantly 5. Is physically aggressive. E.g. Fights, is spiteful, strikes out in temper. NeverRarelySometimesUsuallyFrequentlyConstantly 6. Disrespects property. E.g. Does not value/look after property, damages/destroys, steals. NeverRarelySometimesUsuallyFrequentlyConstantly 7. Uses sexually inappropriate behaviour E.g. Touching, language, intimidation. NeverRarelySometimesUsuallyFrequentlyConstantly 8.Absconding E.g. Truants from lessons, absent from classes. NeverRarelySometimesUsuallyFrequentlyConstantly 9. Offending behaviour. E.g. Known to have been involved in offending behaviour in or out of school. NeverRarelySometimesUsuallyFrequentlyConstantly 10. Involvement with weapons. E.g. Is known to have carried/misused weapons. NeverRarelySometimesUsuallyFrequentlyConstantly Emotional Behaviour 11. Lacks empathy. E.g. Lacks tolerance, sympathy, inconsiderate NeverRarelySometimesUsuallyFrequentlyConstantly 12. Lacks social awareness. E.g. Does not interact appropriately, is a loner, isolated. NeverRarelySometimesUsuallyFrequentlyConstantly 13. Seems unhappy. E.g. Rarely laughs, smiles, is tearful, seems anxious or depressed. NeverRarelySometimesUsuallyFrequentlyConstantly 14. Lacks confidence. Eg. Has low self esteem, fears failure, is shy, afraid of new things. NeverRarelySometimesUsuallyFrequentlyConstantly 15. Is emotionally unstable, lacks self control E.g. Moods unstable, mood swings, impatient, easily flustered, touchy. NeverRarelySometimesUsuallyFrequentlyConstantly 16. Self harm. E.g. Shows signs of self harm, either physical or emotional NeverRarelySometimesUsuallyFrequentlyConstantly 17. Substance abuse. E.g. Known incidences of drug, alcohol misuse. NeverRarelySometimesUsuallyFrequentlyConstantly 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. NeverRarelySometimesUsuallyFrequentlyConstantly 19. Poor learning organisation. E.g. Does not work systematically, is not organised,works at an inappropriate pace, does not have equipment. NeverRarelySometimesUsuallyFrequentlyConstantly 20. Poor communicator. E.g. Speech incoherent, does not think before answering, Limited communication skills, reluctant to speak. NeverRarelySometimesUsuallyFrequentlyConstantly 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. NeverRarelySometimesUsuallyFrequentlyConstantly 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. NeverRarelySometimesUsuallyFrequentlyConstantly 23. Behaviour difficulties in practical lessons. E.g. Behaviour deteriorates in practical subjects. NeverRarelySometimesUsuallyFrequentlyConstantly 24. Has difficulty in social times E.g. Behaviour of concern in break/lunch times, before/after school. NeverRarelySometimesUsuallyFrequentlyConstantly 25. Behaviour of concern on trips. E.g. Concerning behaviour on trips out of school. NeverRarelySometimesUsuallyFrequentlyConstantly [recaptcha]