<p>Referral to the Alternative Education Commissioning Service (AECS), Planning and Provision.</p><p>For pupils unable to attend school due to medical reasons, anxious school refusal or pregnancy.</p><p>Section 1 School information</p><p>Name of school</p><p>Named person for liaison</p><p>Job title</p><p>Telephone number</p><p>Email address</p><p>Section 2 Pupil information</p><p>Name of pupil Date of birth Year group</p><p>Unique pupil Unique candidate number identifier (if applicable)</p><p>Last day of attendance</p><p>Percentage attendance for preceding year (Please attach attendance printout).</p><p>Name of parent/carer Address</p><p>Contact Email telephone address numbers</p><p>Is the pupil a Child in Care (CiC)?Yes / No</p><p>If the pupil has special/additional needs please specify level of support, for example, statement/SA+/ Education Health and Care (EHC) Plan.</p><p>Section 3 Reason for referral</p><p>Please tick as appropriate</p><p>Medical Anxious School Pregnancy Refusal</p><p>For pupils with medical needs</p><p>Please provide details of the medical condition which prevents the pupil from attending school.</p><p>3 Please attach medical evidence.</p><p>4 For anxious school refusers</p><p>Please provide details of the strategies and support offered by the School.</p><p>Please attach medical evidence and evidence of pastoral support.</p><p>For pupils who are pregnant</p><p>Please attach medical evidence of the expected date of delivery.</p><p>Section 4 Other agency involvement</p><p>Please tick relevant boxes.</p><p>General Hospital CAMHS Practitioner Consultant</p><p>School Nurse YOT Social Care</p><p>EWS Other (please specify)</p><p>CAMHS – Child and Adolescent Mental Health Service EWS – Education Welfare Service YOT – Youth Offending Team</p><p>5 Please provide details below:</p><p>Current/recent agency Contact name and address Telephone number and email address</p><p>Section 5 Enclosures</p><p>Enclosure description Please tick if enclosed</p><p>Attendance printout Medical evidence CAF Pastoral Support Programme Reports by other professionals</p><p>Decisions on the appropriateness of provision can sometimes be made on the basis of the referral form and supporting advice and information alone. However, in many cases it is necessary to hold a School Action Plus meeting, involving all the relevant professionals, and if this is the case, the AECS will contact you to ask you to make the necessary arrangements. Continuation of support will depend on the provision of updated medical evidence/advice.</p><p>6 Please note the School’s role is to:</p><p> name a person with whom to liaise;</p><p> host and chair regular review meetings and distribute notes of these meetings;</p><p> provide materials for an appropriate programme of work;</p><p> maintain a plan, such as an IEP, which records progress made towards a return to school;</p><p> ensure all staff are kept informed;</p><p> ensure appropriate arrangements, including entry and invigilation are made for all examinations;</p><p> provide pupils’ academic attainment levels including any relevant examination requirements;</p><p> produce an action plan as a result of the meeting.</p><p>Please ensure that all relevant parts of the form are completed and that the appropriate evidence is attached to the referral. Section 6 Signed by the Head Teacher</p><p>Signature:...... </p><p>Print name:...... Date:...... </p><p>Data Protection Act: The information contained in this form will be held on computer.</p><p>The completed form and evidence should be returned to:</p><p>The Senior Caseworker Alternative Education Commissioning Service 2nd Floor, E Block Email: [email protected] County Hall Telephone number: 03330 131152 Chelmsford, CM2 6WN Fax: 01245 436211</p><p>Authorisation by Alternative Education Commissioning Service (AECS)</p><p>7 Signature...... Principal Officer/Senior Caseworker Alternative Education Commissioning Service</p><p>8 Section 7 Action Plan</p><p>To be completed by the school at the School Action Plus meeting.</p><p>Name of Pupil: School:</p><p>Date of Birth: Date of meeting:</p><p>Agreed Actions: Organisation responsible/Person:</p><p>1. To provide National Curriculum Levels, School standardised test results and IEP.</p><p>2. To fund examination entries and make School arrangements for examination invigilation.</p><p>3. To fund any alternative educational School provision, including college and/or work experience.</p><p>4.</p><p>5.</p><p>6.</p><p>Date of Next Review Meeting:</p><p>The above actions are agreed by: Please sign & print name: Parent/Carer – I also give consent for the school/ Alternative Education Commissioning Service to contact other agencies to discuss my child’s case</p><p>Student:</p><p>School Representative:</p><p>AECS Representative:</p><p>Other Agencies:</p><p>9 CAMHS/EWO/Other:</p><p>10</p>