NEW WOODLANDS SCHOOL
49 Shroffold Road
Downham
Bromley
BR1 5PD
Tel: 020 8695 2380
Headteacher: Mr. D. Harper
Deputy: Miss C. Warner
REFERRAL FORM TO ACCESS PLACEMENT AT NEW WOODLANDS
SECTION 1
Child’s Name:
D.O.B
Year
UPN Number
ULN NUMBER –
ETHNICITY
KS3 Y9 only
SCHOOL:
BOROUGH OF
RESIDENCE
NAME OF REFERRER (person completing
this form)
POSITION:
HEAD’S NAME:
CONTACT NUMBER:
EMAIL:
DATE:
Is the child welcome to return to your school if they meet New Woodlands’ readiness for
reintegration criteria? (circle)
YES
NO
If the child is not welcome to return to your school please explain why
Headteacher’s signature:
Date:
Parental Consent
I have read the above and consent to my child being referred for a placement to New
Woodlands School.
Parent/Carer’s signature:
Date:
2014-15
Name of Adult with Parental
Responsibility:
ADDRESS
Home Telephone
Mobile
SECTION 2
OTHER INFORMATION ABOUT CHILD (Tick)
]
On Child Protection
Looked After Child – state Free School Meals [circle]
Register
Authority that has
responsibility
YES
NO
PLEASE ENSURE YOU
NOTIFY NEW WOODLANDS
OF ANY CHANGES
Previous schools/provisions attended with dates and reasons for leaving:
2014-15
SECTION 3 : Special Educational Needs/Support
Does the student have a statement of Special Educational Needs or an Educational,
Health and Care plan? (circle)
YES
NO
If the student has a statement or an EHCP has an emergency review taken place
where this referral to New Woodlands was agreed? (circle)
YES
NO
If the child does have a statement or EHCP please attach a hard copy of statement/EHCP
to this referral form. You will also need to send by email an electronic copy of this to
either Jayne West for primary children or Carlie Warner for KS3 children.
j.west@newwoodlands.lewisham.sch.uk
c.warner@newwoodlands.lewisham.sch.uk
Please TICK which of the following apply:
CHILD HAS NO SPECIAL EDUCATIONAL NEEDS
CHILD IS RECEIVING SEN SUPPORT
CHILD IS RECEIVING OR HAS RECEIVED OUTSIDE
AGENCY SUPPORT
CHILD IS UNDERGOING ASSESSMENT FOR AN EHCP
Has the child been diagnosed with any of the following [PROVIDE DATES &
PERSON WHO COMPLETED DIAGNOSIS + attach copy of paperwork]
DIAGNOSIS
TICK
Name & Date
ADHD
ASD
ODD
CONDUCT
DISORDER
ATTACHMENT
DISORDER
DYSLEXIA
LANGUAGE
DISORDER
2014-15
Support Child has received
Please give details of the support offered to this student and attach any relevant reports.
Internal Support (e.g In class support/One to One withdrawal/Literacy
Group/Numeracy Group/Mentoring/ Social Skills Group/ Counselling etc)
Type of support
Dates (Start and
End dates/please
state if ongoing)
Aim
Outcome
External Support (e.g CAMHS, Speech and Language Service, Social Services,
YOS, Educational Psychologist etc..)
Type of support
and person
delivering this
support (please
also include their
contact details)
New Woodlands
Outreach Service
Name of Outreach
Teacher:
2014-15
Dates (Start and
End dates/please
state if ongoing)
Aim
Outcome
SECTION 4: BEHAVIOUR - REASONS FOR REFERRAL
Please detail what has led to this referral and why New Woodlands would be
considered an appropriate placement for this student:
GIVE 3 SPECIFIC BEHAVIOUR TARGETS YOU WOULD LIKE TO SEE THIS
STUDENT ACHIEVE DURING THEIR PLACEMENT
1.
2.
3.
2014-15
Prioritise the 3 BEHAVIOURS OF CONCERN the student gets involved in [1 worst,
2,3 etc]:
Threatening Behaviour to
Verbal Abuse to staff
Verbal Abuse to Peers
Staff
Threatening Behaviour to
Peers
Physical Abuse [assault] to
Peers
Self Harming/ Depressed
Physical Abuse [assault] to
Staff
Gang Involvement
Drugs/ Alcohol Related
Damage to Property
Truancy
Theft
Racist
Sexual Misconduct
Bullying
Persistent Disruptive
Behaviour
Disobedience/Not following Other
instructions
2014-15
In order to meet student needs and to risk assess effectively, we need the following
information. Please complete table below
Behaviour
Date
Details Of Incident
Consequences/Action
Harm to self or others
Sexualised Behaviour
Criminal Behaviour
Drug/Alcohol/Solvent
Abuse
Police involvement? Circle
YES
Details
2014-15
NO
SECTION 5 : Attendance
Student Attendance for this term:
%
Student Attendance for last 12 months:
%
Number of days excluded over the last
12 months:
SECTION 6: Educational Information
Current Literacy/English Reading Level
Current Literacy/English Writing Level
Current Numeracy/Maths Level
KS2 SATs Levels (please include for all
KS3 students being referred)
Literacy:
Numeracy:
KS1 SATs Levels (please include for all
KS2 students being referred)
Literacy:
Numeracy:
What kind of learner is this student?
Please detail what type of lessons this student enjoys and why.
Please state the curriculum areas that this student may find challenging
2014-15
Checklist:
Please ensure that all the above sections on the form are completed. If these items
are not completed satisfactorily the form will be returned to you for completion
before we can make a decision on placement.
Please ensure that a CAF for this student is also completed/updated. Please make
sure this is also attached with this referral form. Please also ensure that the CAF is
signed by the referrer and parent/carer.
Please ensure that the following are also attached with the placement referral form
and CAF.
1)
2)
3)
4)
5)
Statement/EHCP where relevant
Attendance print out
Behaviour Log/ Incident reports
Outside agency reports (especially those where a child has received a diagnosis)
Reports from school professionals involved (especially those detailing the internal
support the child has received)
6) Any school reports detailing current attainment.
2014-15
OFFICE USE
DATE OF MEETING :
COMMENTS
2014-15