Mendip Partnership Referral Form

Your first name *

Your last name *

Your email *

Name of referring school *

Referral type

Full-time partnership place

Part-time partnership place

Direct support in school

Advice, guidance and support

Partnership programme

Transition Support

Learner's Name *

Learner's Date of Birth *

UPN

ULN

Gender *

Male

Female

Prefer not to say

Year Group *

Has the learner been in receipt of free school meals within the last 6 years? *

Yes

No

Maybe

Learner's address *

Home contact name *

Home contact address (if different from learner)

Home contact telephone number *

Home contact email address

Home language

Is the learning on the child protection register? *

Yes

No

Is the learner child looked after? *

Yes

No

Does the learner access any other support services? *

Yes

No

Name of professional agency

Agency / Professional contact name

Agency / Professional contact telephone number

Details of Agency / Professional involvement

SEN status *

N - no special educational need

K - SEN support

E - EHCP

Percentage of attendance *

Reason for referral (please give as much details as possible) *

Please outline any work or strategies that you have carried out with the learner to address difficulties (please give as much details as possible) *

Evidence of criminal activity *

Low

Medium

High

Evidence of bullying *

Low

Medium

High

Evidence of sexualised behavour *

Low

Medium

High

Evidence of arson / fire setting *

Low

Medium

High

Evidence of verbal abuse to peers *

Low

Medium

High

Evidence of physical abuse to peers *

Low

Medium

High

Evidence of verbal abuse to adults *

Low

Medium

High

Evidence of physical abuse to adults *

Low

Medium

High

Concerns around attendance and punctuality *

Low

Medium

High

Evidence of self-harm *

Low

Medium

High

Evidence of anxiety *

Low

Medium

High

Evidence of lesson disruption / sabotage *

Low

Medium

High

Evidence of racism or homophobic behaviour *

Low

Medium

High

Evidence of alcohol/ substance abuse *

Low

Medium

High

Concerns around parental support *

Low

Medium

High

Concerns around mental health *

Low

Medium

High

Concerns around medical needs *

Low

Medium

High

Concerns around social anxiety/isolation *

Low

Medium

High

Possession of weapons *

Low

Medium

High

Leaving site without permission *

Low

Medium

High

Gang or County Lines involvement *

Low

Medium

High

Do you have parental consent for this referral? *

Yes

No

Date of parental consent *

Person agreeing to this referral from mainstream school *

Date of this referral *