Online Referral Form

Confidential

Student Referral Form

Please complete all sections accurately. All information is treated in strict confidence.

1
Student &
School
2
Parent &
Referral
3
Concerns &
Learning
4
Behaviour
Matrix

Student Details

Step 1 of 4
School Information
Status Flags

Primary Contact — Parent / Carer

Step 2 of 4

Emergency Secondary Contact

Referral Details

Point of Contact at Base School

Agencies, Medical & SEN

Step 3 of 4

Attendance & Exclusions

Concerns at School

Learning

Concerns at Home

Preferred Referral Outcome

CONDUCT Behaviour
Behaviour NeverRarelySometimesUsuallyFrequentlyConstantly
Behaves disrespectfully towards teacher Is impolite, disrupts, intimidates, deliberately annoys, verbally aggressive.
Lacks respect for other students Name calling, swearing, psychological intimidation, bullying.
Is verbally abusive Racial, gender, religious, or learning disability abuse.
Seeks attention inappropriately Disrupts or distracts others, interferes, misuses equipment.
Is physically aggressive Fights, is spiteful, strikes out in temper.
Disrespects property Does not value or look after property, damages, destroys, or steals.
Uses sexually inappropriate behaviour Touching, language, intimidation.
Absconding Truants from lessons, absent from classes.
Offending behaviour Known to have been involved in offending behaviour in or out of school.
Involvement with weapons Is known to have carried or misused weapons.
EMOTIONAL Behaviour
Behaviour NeverRarelySometimesUsuallyFrequentlyConstantly
Lacks empathy Lacks tolerance, sympathy, inconsiderate.
Lacks social awareness Does not interact appropriately, is a loner, isolated.
Seems unhappy Rarely laughs or smiles, is tearful, seems anxious or depressed.
Lacks confidence Has low self-esteem, fears failure, is shy, afraid of new things.
Is emotionally unstable, lacks self-control Moods are unstable, mood swings, impatient, easily flustered, touchy.
Self-harm Shows signs of self-harm, either physical or emotional.
Substance abuse Known incidences of drug or alcohol misuse.
LEARNING Behaviour
Behaviour NeverRarelySometimesUsuallyFrequentlyConstantly
Is inattentive Poor concentration, poor motivation, easily frustrated.
Poor learning organisation Does not work systematically, is not organised.
Poor communicator Speech incoherent, limited communication skills, reluctant to speak.
Does not work efficiently in a group Does not take part or contribute in groups, does not work collaboratively.
Does not seek help when necessary Refuses tasks in the face of difficulty, cannot cope with challenges.
Behaviour difficulties in practical lessons Behaviour deteriorates in practical subjects.
Has difficulty in social times Behaviour of concern at break, lunch, before or after school.
Behaviour of concern on trips Concerning behaviour on trips out of school.

Completion Details