Section 1 Personal Details s1

VERSION 05.09 11

EDUCATIONAL PSYCHOLOGY SERVICE STAGE 3 REFERRAL FORM This form is confidential to parents/persons responsible for and those professionally involved with the child. This form together with the accompanying Appendix A ‘Equality Monitoring’ form should be completed only when referral at Stage 3 of the Code of Practice has been agreed following Consultation with the Educational Psychologist. The parents/persons responsible and school Principal should sign and date the final page.

Name of Educational Psychologist …………………………………… Referral agreed Yes / No

SECTION 1 PERSONAL DETAILS

Child's Name...... Date of Birth ......

Child's Address ……………………………………. Chronological Age …………………………………….

……………………………………………………….. Gender …………………….

……………………………………………………….. Post Code ……………………………………………..

Telephone No ………………………………………

Present school ...... Date of enrolment ……………………………………..

Class ...... Class/Form Teacher …………………………………..

Previous school(s) ……………………………………… SENCo ………………………………………………….

List everyone who has parental responsibility for the child in accordance with the Children (NI) Order 1995. (Continue on a separate sheet if necessary)

Name...... Relationship to child ......

Address ......

Telephone No (i) Home...... (ii) Work...... (iii) Mobile ......

Name ...... Relationship to child ......

Address ......

Telephone No (i) Home...... (ii) Work ...... (iii) Mobile ......

Name...... Relationship to child ...... ……..

Address ......

Telephone No (i) Home …………………….. (ii) Work …………………… (iii) Mobile…………………………..

1 Additional Personal Information Give details of any orders under child care law which affect the child e.g. Care Order, Supervision Order

......

Are there any family circumstances about which the Education Authority should be aware in making contact with parents/carers, for example, is the child’s first language English?

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SECTION 2 REASON FOR REFERRAL Indicate difficulty/difficulties in order of priority: 1, 2, 3 etc.

Learning Difficulties Specific Learning Difficulties/Dyslexia

Social, Emotional and Behavioural Difficulties Physical Difficulties

Sensory Difficulties (Hearing and/or Social/Communication & Interaction Visual) Difficulties

Speech & Language Difficulties Medical

Other (Please specify) …………………………………………………………………………………………………

SECTION 3 BACKGROUND INFORMATION Please describe the nature of the child’s difficulties, as perceived by the school. ………………………………………………………………………………………………………………………... …………………………………………………………………………………………………………………….….. ………………………………………………………………………………………………………………………..

Factors which may have contributed to child's difficulties (e.g. hearing, vision, speech problems, familial circumstances, irregular attendance, change of school)

...... What do you expect from this referral? …………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………… 2 Please outline current support from the school at Stages 1 to 3 and comment on its effectiveness. Please attach copies of Education Plans and records of the reviews of these plans. ………………………………………………………………………………………………………………………... ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… Other professional involvement:

Community Paediatrics Counselling Service

Speech & Language Therapy Education Welfare Service

Occupational Therapy Autism Support Service

Physiotherapy Behaviour Support Services

Youth Justice Child & Adolescent Mental Health Service

Social Services Child Development Clinic

Multi-agency School Support Service Pre-school Support Service

Sensory Support Service Other ______

Please provide details of interventions and enclose copies of available reports ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………

SECTION 4 DESCRIPTION OF CHILD’S FUNCTIONING (as appropriate to age and development) A) COGNITIVE/INTELLECTUAL ABILITY ...... B) LANGUAGE AND EMERGING ACCESS SKILLS (i) Receptive: ……………………………………………………………………………………………………… ...... (ii) Expressive:...... (iii) Clarity of speech: ……………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………………… 3 (iv) Emerging Literacy: …………………………………………………………………………………………………….. ……………………………………………………………………………………………………………………….. …..

(v) Emerging Numeracy:...... C) GROSS AND FINE MOTOR SKILLS ...... D) SELF-HELP AND INDEPENDENCE SKILLS ...... …………………………………………………………………………………………………...... E) SENSORY ISSUES Please provide details, where available, on (i) Hearing: ………………………………………………………………………………………………………… …………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………… ………. (ii)Vision: ………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………….. (iii) Other sensory concerns:…………………………………………………………………………………………………. ………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………… ………….

SECTION 5 ATTAINMENTS (as appropriate to age and development)

A) LITERACY (i) Reading Accuracy:………………………………………………………………………………………………………..

...... (ii) Reading Comprehension:………………………………………………………………………………………

...... (iii) Spelling:…………………………………………………………………………………………………………………… 4 ...... (iv) Writing: Please attach a specimen of child’s written work if relevant ...... B) NUMERACY ......

SECTION 6 MOST RECENT STANDARDISED TEST RESULTS

Name of Test Date Age at Standardised Age of Test Testing Score Equivalent

Cognitive

Accuracy Reading Comprehension

Spelling

Mathematics

Language

InCAS TEST RESULTS including previous years’ results if available

Standardised Age Subject Date of Test Age at Testing Score Equivalent

5 6 SECTION 7 SOCIAL, EMOTIONAL, PSYCHOLOGICAL AND BEHAVIOURAL FACTORS i) Child’s perception of his/her difficulties:………………………………………………………………………………… ...... …………………………………………………………………………………………………………………………….. ii) Child’s strengths and interests in school or at home: ………………………………………………………………… …………………………………………………………………………………………………………………………….. …………………………………………………………………………………………………………………………….. iii) Social skills and relationships e.g. interaction with peers/adults:……………………………………………………...... iv) Emotional well-being:……………………………………………………………………………………………………...... …………………………………………………………………………………………………………………………….. v) Ability to take turns, to share and to co-operate with others in class and/or playground:…………………………...... …………………………………………………………………………………………………………………………….. vi) Attention, concentration and impulsivity:……………………………………………………………………………….

...... …………………………………………………………………………………………………………………………….. vii) Play skills as appropriate:………………………………………………………………………………………………...... ……………………………………………………………………………………………………………………………… viii) Understanding of, acceptance of, and response to class and school routines and rules:………………………...... …………………………………………………………………………………………………………………………………. ix) Additional information regarding behaviour:……………………………………………………………………………

...... ………………………………………………………………………………………………………………………………….. x) Child’s attitude/motivation: ………………………………………………………………………………………………..

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7 SECTION 8 PRINCIPAL’S AGREEMENT TO REFERRAL

Signature of Principal ...... Date ......

PLEASE TICK TO CONFIRM ENCLOSURES:

 The two most recent Individual Education Plans – with outcomes

 Professional report(s) e.g. Private Educational Psychology, Medical, Therapy or Social Services

 Sample of child’s work if relevant

 Other (please specify) ......

SECTION 9 PARENTAL VIEWS AND AGREEMENT TO REFERRAL

I have read and discussed this completed referral form with my child’s school and agree that the information provided within is accurate. I wish to make the following comments/observations.

...... I agree to the referral form and any relevant reports being forwarded to the Educational Psychology Service. . I understand that I may contact the Psychologist prior to assessment. . I also understand that I may discuss with the Psychologist whether I should be present during my child’s individual assessment. . I understand that the Psychologist will discuss the assessment with me. The information on this form is required by the Education Authority for the purpose of assessing the child named on the first page. The information is covered by the provisions of the Data Protection Act 1998. Your signature to the form is deemed to be an authorization by you to allow the Education Authority to process and share this information with relevant Education and Health professionals involved with your child.

Signed ...... Date ......

Parent(s) or person(s) exercising parental responsibility

PLEASE ENSURE THAT COPIES OF EDUCATION PLANS IMPLEMENTED AND REVIEWED ARE ATTACHED TO THIS FORM. FAILURE TO DO SO MAY RESULT IN A DELAY IN THE DECISION TO ACCEPT THIS STAGE 3 REFERRAL.

Please return completed referral form to the relevant Educational Psychology Regional Office:

Schools in the Coleraine, Schools in the Schools in the Ballymena, Schools in the Newtownabbey Ballymoney and Moyle Regions Magherafelt Region Antrim and Larne Regions and Carrickfergus Regions Northern EPS Regional Office Central EPS Regional Office Loughview EPS Regional Office Schools Campus The Chalet Southern Regional Office Carthall Road 182 Galgorm Road 2 – 6 Jordanstown Road Coleraine, Ballymena Newtownabbey Co Londonderry Co. Antrim County Antrim BT51 3LR BT42 1HN BT37 0QF 8 Appendix A Education Authority North Eastern Region

SEN DATA COLLECTION

This pro forma is to be used for the purpose of obtaining a pupil profile for Equality Monitoring at Stage 3 referral. It should be cross referenced with the pupil’s file but should preserve the pupil’s anonymity.

There are three sections to be completed that will augment information provided by the Educational Psychology Service Stage 3 Referral Form.

Pupil Reference Number: ______Date of Referral: ______(The existing Education Authority pupil reference number to be used) 1. Protestant Catholic Perceived Religious Belief

Non - Other determined

2. Race/Ethnic Origin:

Please indicate which ethnic group the pupil belongs to:

White: Bangladeshi:

Irish Traveller: Black – Caribbean:

Pakistani: Black – African:

Chinese: Black – Other:

Indian:

(Please specify) Mixed Ethnic Group:

Any other Ethnic Group: (Please specify)

3. Is the pupil a – School-age Mother? YES NO - Young Carer? YES NO (circle as appropriate)