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Curriculum Statement
English / Literacy
Maths / Numeracy
Primary
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Alternative Provision
Contact
Mendip Partnership and Well Being Board Referral Form
Name of referring school
Contact Person
Telephone number
Contact email
Referral Type
Full time partnership place
Part time partnership place
Managed move brokerage
Advice guidance and support
Direct support in school
Assessment place
Partnership Programme
Learner Forename
Learner surname
Preferred name
Date of Birth
DD slash MM slash YYYY
UPN
ULN
Gender
Male
Female
Prefer not to say
Year Group
1
2
3
4
5
6
7
8
9
10
11
Has the learner been entitled to free school meals in the last 6 years
Yes
No
Learner home address
Contact 1 Name
Contact 1 Address
Contact 1 Telephone number 1
Contact 1 Telephone number 2
Contact 2 Name
Contact 2 Address
Contact 2 Telephone number 1
Contact 2 Telephone number 2
On Child Protection Register
Yes
No
Child looked After
Yes
No
Other support services
Yes
No
Workers name
Workers Agency
Workers Telephone
Workers email
Details of current involvement
Workers name 2
Workers Agency 2
Workers Telephone 2
Workers email 2
Details of current involvement 2
Ethnicity
Home language
Religion
SEN status
N-No special need
K- SEN support
S- Statement
E- Education Health and Care Plan
In receipt of high needs funding
Yes
No
Band
Key Stage 2 English
Key Stage 2 maths
Attendance - Number of possible sessions
Attendance - Number of sessions attended
Attendance - Number of unauthorised absences
Reason for referral
Please give as much detail as possible
Please outline any work or strategies that you have carried out with the learner to address difficulties
Give as much detail as possible and state whether this was successful or not
Evidence of criminal activity
Low
Medium
High
Evidence of bullying
Low
Medium
High
Evidence of sexualized behaviour
Low
Medium
High
Evidence of arson or 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
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
MM slash DD slash YYYY
Person agreeing to this referral from mainstream school
Date of this referral
MM slash DD slash YYYY
Comments
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