Appendix 1
Secondary Panel for Inclusion: Referral Form
(Please ensure ALL boxes are completed)
A Common Assessment Framework (CAF) or Personal Education Plan (PEP) MUST be
completed and attached to this referral.
Please tick as appropriate
– CAF □
– PEP □
Please indicate which service this referral is for:
□ Managed Pupil Transfer
□ Highfields PRU placement
□ Pendlebury Centre placement
□ ACE placement
□ Cedars placement
Name of Pupil:
DOB:
/
Parent / Carer:
Telephone:
/
Year Group:
Address:
UPN:
UCI No:
Free School Meals: Yes □ / No□
Pupil Premium: Yes □ / No□
SEN Stage:
School Action □
(KS4 only)
School Action Plus □
Statement □
(If pupil is on SEN register, please indicate whether
it is for learning, behaviour or a combination)
Is the pupil subject to Child Protection Plan? Yes
□ Social Worker:
(Please provide additional information if YES)
No
□
Is the pupil a Looked After Child (LAC)?
Yes
□ Social Worker:
(Please provide additional information if YES)
No
□
Is the pupil involved with CAMHS?
Yes
□ CAMHS Consultant:
(Please provide additional information if YES)
No
□
Referring School/Service:
Date of Referral:
Person Referring:
Role:
Contact Tel No:
Does this referral have parental support?
(It is essential that all referrals have full parental support)
Yes
□
No
□
Supporting Information & Documentation – Referral Checklist
All referrals require a CAF or PEP
In addition to the CAF or PEP, the following documents should be attached to the referral form.
Please indicate the supporting information enclosed
Pendlebury Centre PRU placement
 Reason for the referral
 Summary of pupil’s presenting
behaviours/difficulties
 Support strategies implemented and
outcomes
 Current Psychologist report
(Pupil should have been seen by an
Educational Psychologist in the previous
4 months), AND / OR
 Medical/CAMHS advice
 Information about all other agencies
involved, e.g. Social Care, YOS etc.
 Attendance data for current and previous
academic year
 SEN info including copy of IEP, IBP or
statement
 Minutes of any relevant meetings, e.g.
TAC, CP, review meetings etc.
 Information to show levels of attainment
 Academic Tracking Information sheet
(Appendix 4)
 SEBD criteria referral checklist
completed and signed by Educational
Psychologist (Appendix 3)
 Completed and scored Devereux
Cedars placement
In addition to the above you need to provide:
 Consultant Psychologist / Psychiatrist
Assessment
 If LAC, Social Care Assessment / Report
Managed Pupil Transfer
 Behaviour log / Incident reports
 Information about all agencies involved,
e.g. Social Care, YOS etc.
 Attendance data for current and previous
academic year
 Risk Assessment (Appendix 8)
 Behaviour Profile (Appendix 9)
 Most recent IEP, IBP or PSP
 Information to show levels of attainment
 Details of completed coursework,
examination subjects & boards (KS4 only)
Highfields PRU placement
 Reason for the referral
 Summary of pupil’s presenting
behaviours/difficulties
 Behaviour log
 Support strategies implemented and
outcomes
 Information about all other agencies
involved, e.g. Social Care, YOS etc.
 Risk assessment (Appendix 8)
 Behaviour profile (Appendix 9)
 Attendance data for current and previous
academic year
 SEN info including copy of IEP, IBP or
statement
 Pastoral Support Plan (PSP)
 Minutes of any relevant meetings, e.g.
TAC, CP, review meetings etc.
 Medical advice
 Information to show levels of attainment
 Details of completed coursework,
examination subjects & boards for KS4
students
ACE placement
In addition to the above you need to provide:
 ACE criteria referral checklist (Appendix 7)
 ASSET Assessment (via YOS) AND / OR
 Social Care Core Assessment
 Minutes of the multi-service planning
meeting which recommended ACE
placement (ACE Co-ordinator or HIP
Headteacher should be in attendance)
Return to:
Zhenab Naeem
SPI Referral Coordinator
Education Access Service,
Services to People,
Stopford House, Stockport, SK1 3XE
Tel: 0161 474 3972
Fax: 0161 953 0012
eas@stockport.gov.uk
Please Note: Completed referrals will be
accepted up to 4pm on the Friday before a
Panel meeting.