Parental signature must be obtained prior to referral
SALFORD LEARNING SUPPORT SERVICE
REFERRAL FORM
Child’s Name
D.o.b.
School year group:
Language spoken
Gender
Attendance %
Child’s address
New arrival to school / UK? Yes / No
Home phone number
Name of parent / guardian
First / home language
School name / address
LAC yes / no
Phone number
Email address
Name of Head Teacher
Name of class teacher
Name of SENCo / EAL coordinator/Inclusion Manager
Other professional involved (including agency contact details):
Is the child considered to be in need of Additional Special Support?
Please indicate band A / B / C if known
Does the child have a Statement of Special educational needs, or an EHC plan?
PRIMARY AREA OF CONCERN: PLEASE INDICATE ONE ONLY
TICK ONE
Social and communication difficulties (including ASC) (attach checklist)
Dyslexia (spld) (age 7 years and above only)
Dyscalculia / numeracy
Hearing impairment (hi)
Multi-sensory impairment (msi)
Physical difficulties / OT needs(PD)
Speech, language and communication needs (SLCN) (attach checklist)
Visual impairment (vi)
Social emotional and mental health needs
Global developmental delay / moderate learning difficulties
Other (please specify)
WHEN COMPLETE PLEASE RETURN SIGNED FORM AND ACCOMPANYING DOCUMENTS TO
LSSreferrals@salford.gov.uk
Parental signature must be obtained prior to referral
How confident do you feel about being able to support this pupil’s needs?
Not very
Fairly
Ok
Good
1
2
3
4
Very good
5
Particular areas of need, including medical diagnosis if appropriate
What additional strategies / resources are / have been provided in school:
Y/N
Support staff / time allocation
Curriculum resources
Specialist equipment
CAMHS
Individual / group learning plans /
individual targets
Building adaptations
ELKLAN
ECAR / ECAT
Visual aids e.g. visual timetables, nownext, objects of reference etc
Specific staff training **
Team Teach
Dyscalculia screener
Y/N
IDP / online training materials
SALT
EP
Other therapist input**
Targeted group work eg anger
management, social skills
Individual work stations
Alternate recording methods
Social stories
Specific programmes eg Toe-ByToe, Power of 2**
Dyslexia screener
Positive handling plan
Other **
** please give details .............................................................................................................
.............................................................................................................
Please complete the following:
Academic
attainment e.g.
emerging /
developing/ secure.
Is this child / young person making
progress
Please indicate Y / N
a) Year on
year?
b) Compared to peers?
ENGLISH
Reading
Writing
WHEN COMPLETE PLEASE RETURN SIGNED FORM AND ACCOMPANYING DOCUMENTS TO
LSSreferrals@salford.gov.uk
Parental signature must be obtained prior to referral
Speaking and listening
MATHS
Using and applying
Number
SSM
Data handling
Reading age
Spelling age
Please attach other relevant evidence in support of request e.g. statement of SEN / EHCP, EP
report, records of individual targets and evaluation of success against these.
How do you envisage Salford LSS being able to support you in meeting this child’s needs?
Discussion with generic teacher:
Referral recommended by _____________________________________________
Designation
_____________________________________________
I confirm that I have seen the referral form and am in agreement with ...................................
being referred to the Learning Support Service.
Signed
Parent /Carer _____________________________________
Date_______________
School – LSS Partnership agreement
WHEN COMPLETE PLEASE RETURN SIGNED FORM AND ACCOMPANYING DOCUMENTS TO
LSSreferrals@salford.gov.uk
Parental signature must be obtained prior to referral
School /setting will:
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Provide current, up to date academic data for the young person;
Provide up to date targets and plans where appropriate;
Inform the pupil of the planned intervention;
Ensure a member of staff is designated to liaise with the LSS and also between the LSS and
other appropriate personnel e.g. teachers, parents etc;
Release a member of staff when required to facilitate joint working e.g. modelling, training,
observations, discussions, to increase the schools’ ability to meet the needs of the young
people more effectively;
Give notice of changes which may affect the LSS work e.g. school closures, pupil absence;
Implement agreed advice and support outside of the times when the LSS is directly involved
with school / setting or the young person;
Participate in monitoring, review and evaluation process;
Provide an appropriate environment as needed when requested by LSS staff e.g. for
meetings, for 1-1 work outside of the classroom environment.
The LSS will:
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Provide advice and strategies as needed as a result of observations and assessment;
Provide time limited 1-1 work with young people where deemed necessary by LSS staff;
Provide written reports in a timely fashion to inform school of interventions and progress,
and also for Annual Reviews as necessary (within 1 term of input);
Attend meetings relating to the child e.g. TAC meetings, CAF meetings, Annual Review
meetings, as deemed necessary / appropriate (within 1 term of input);
Work with school staff (teachers, teaching assistants, senco’s) and provide training and
support as deemed necessary, for which school may be charged;
Provide details of planned interventions;
Work jointly with school / setting in the evaluation of progress.
Senco / named person _______________________________
Date _______________
Head teacher / health professional _____________________
Date _______________
WHEN COMPLETE PLEASE RETURN SIGNED FORM AND ACCOMPANYING DOCUMENTS TO
LSSreferrals@salford.gov.uk