Mspec Intervention Referral

MSPEC INTERVENTION REFERRAL FORWARD/EMAIL completed form and all relevant information to MSPEC ([email protected]) (Form Vers.18, 20170608) Date of MSPEC Intervention Referral Submission to CEDoW: Triple click here to enter text

Triple click Triple click Triple click Date of Student Name: Triple click here to enter text here to enter Year/Grade: here to enter Gender: here to enter Birth: text text text Teacher: Click here to enter text. School: Triple click here to enter text If other specify: Click here to enter text Case Manager: Click here to enter text. Is the school receiving additional SWD Indigenous New Arrival Other (Give details) funding for this student? Has the Parent/Care r been Yes No notified of this referral?

PRINCIPAL’S AUTHORISATION It may be necessary for CEO personnel to have some direct involvement in order to collaboratively determine the most appropriate intervention strategies. This may include observing the student in-situ (eg. playground, classroom, etc). Has the Principal authorised this request? Yes No URGENT response required. (Student is deemed to be at significant risk of harm to self or others and/or student is at risk of suspension)

SECTION A – RELEVANT AREAS Indicate ALL RELEVANT AREAS for this referral and attach appropriate documentation Behaviour Indigenous Work Health & Safety Gifted Literacy Formal Risk Assessment Psychometric Assessment Pastoral EAL/D Student with Disability Safety, Welfare & Wellbeing Attendance Concerns New Arrival Sensory/Hearing/Vision Medical eg Epilepsy/Diabetes etc Mental Health Receptive and/or Numeracy Expressive language delay Child Protection Tick if also relevant with this student NB: Child Protection referrals to CEO are made directly to Child Protection, not via MSPEC. Email [email protected] or phone

SECTION B – KEY EDUCATION DETAILS Most recent NAPLAN Bands

Numeracy: Triple click here to enter BANDS Reading: Triple click here to enter BANDS Writing: Triple click here to enter BANDS Spelling: Triple click here to enter BANDS Punctuation & Grammar: Triple click here to enter BANDS Syllabus outcomes student currently demonstrating: Mathematics: Stage Triple click here to enter STAGE English: Stage Triple click here to enter STAGE Regular Syllabus outcomes all courses Life Skills outcomes all courses Combination of Life Skills & Regular Syllabus outcomes

Existing Diagnosis: Specify: Triple click here to enter SPECIFY

Is there case management for this student? Yes (include a copy of the report) No Participation in, or currently, in Reading Recovery? Yes(include a copy of the report) No

Has student been referred off Reading Recovery? Yes(include a copy of the report) No

CEDoW | MSPEC Intervention Referral Form | V17 | 2017 2 SECTION C – OTHER KEY INFORMATION, HEALTH PROFESSIONALS INVOLVED, REPORTS AND PLANS

Please note, or request (from Parents(s)/Carer wherever possible) additional health professional information or other agency reports, prior to submitting this CEDoW referral.

Attach any documentation that is not on file with CEDoW.

PROFESSIONALS INVOLVED Paediatrician: Triple click here to enter DATE Hearing: Triple click here to enter DATE Psychiatrist: Triple click here to enter DATE Speech: Triple click here to enter DATE CEDoW Psychologist: Triple click here to enter DATE Other Health Professional: Triple click here to enter DATE Psychologist: Triple click here to enter DATE Other Agencies: Triple click here to enter DATE Vision: Triple click here to enter DATE CatholicCare Counsellor: Ongoing Completed

Have the strategies/recommendations from the health professional or other agency reports been implemented? Yes No Partially N/A

Do you have a signed Release of Information Form for professional involved if this information is not readily available? Yes No

PLANS IN PLACE – Please attach copies of all plans NSWCEC Personalised Plan (PP) Behaviour Support Plan Health Plan Personalised Learning Plan (Aboriginal/Torres Strait Islander) Risk Management Plan Safety Plan Mental Health Care Plan Other, Please specify, Enter text here

OTHER History of: Middle Ear Infections Common Colds Grommets Other

SECTION D – Indicate the Main Reason/s for Seeking Referral Learning Support

Attach MSPEC Committee Notes and/or relevant documentation

Curriculum Access Communication Mobility Safety Personal Care Social/Emotional Classroom Observation Psychometric Assessment Gifted Education Acceleration SWD (Please state category of disability): Enter text here

Psychometric Assessment Application (Please tick all Relevant Boxes)

Attach all relevant MSPEC documentation including notes to support the psychometric assessment request.

1. State the number of years fluent English has been spoken by the student. Enter text here years

2. This request is from: School Concern Paediatrician (Attach letter) Health Professional (Attach letter)

3. Do you suspect any underlying conditions (eg. Anxiety, Autism, Intellectual Disability, Oppositional Defiance Disorder (ODD), Attention Deficit Hyperactivity Disorder (ADHD) or a Specific Learning Disorder) Yes No

If yes, please include/attach a brief description of your concerns and the student’s behaviours and Individual Plans Triple click here to enter text

CEDoW | MSPEC Intervention Referral Form | V17 | 2017 3 4. Has the student had a psychometric assessment within the last 3 years? Yes No

Work Health & Safety

Attach Forms and all relevant documentation Safety of person/s: Employee Student Volunteer Contractor Member of Religious Order Forms completed Register of Injuries Student Accident Report Accident/Incident Investigation Risk Assessment Other.Enter text here

Staff/Leader Capacity

Attach Forms and all relevant documentation Staff member(s): Teacher SSO Middle Leader Principal Other. Enter text here

Complete for all referrals Description of reason for referral: Triple click here to enter text

Successful strategies: Triple click here to enter text

Less successful strategies: Triple click here to enter text

CEDoW | MSPEC Intervention Referral Form | V17 | 2017 4 What do you hope will be achieved as a result of this referral: Triple click here to enter text

Please attach all relevant MSPEC documentation. Please note this documentation should provide information regarding the intervention strategies that have been implemented at the school level.

FORWARD/EMAIL completed form and all relevant information to MSPEC ([email protected]) If posting additional information to CEDoW, send to: Attention: Confidential - MSPEC Catholic Education Office Locked Mail Bag 8802 WOLLONGONG NSW 2500

CEO OFFICE USE ONLY

SI-Primary SI-Secondary SI-SS WH&S

Date Received: Click here to enter a date.

CEO Team Leader: Click here to enter text.

CEDoW | MSPEC Intervention Referral Form | V17 | 2017 5