<p> 2015/2016</p><p>Primary Referral Form to Fair Access Pupil Placement Panel For Office Use Only Referral Number Referred by: Date Form Completed: Tel No: Email:</p><p>1. Referral & Recommendations Child Details Name: Other Names: Male Female Ethnicity: UPN: Date of Birth: Y e a r</p><p>G r o u p Current Preferred Provision/School School/type of School</p><p>Reason for Referral and provision requested where appropriate: Name of Lead Professional: (See Page 7, Type of provision/assessment )</p><p>Strengths (Academic and Social):</p><p>Attitude to Work:</p><p>Parent/Carer view: 1. FAP 2015-16 Pupil view:</p><p>Risk Assessment for placement at short stay school (PRU): Please describe any intervention or adaptation that has proved effective in the past</p><p>Medical Needs (please provide details): Medical:</p><p>Known Allergies:</p><p>Dietary Requirements:</p><p>Accessibility Issues:</p><p>Parent/Carer Information (1): Parent/Carer Name: Relationship: Tel No: Email: Address: Postcode:</p><p>Parent/Carer Information (2): Parent/Carer Name: Relationship: Tel No: Email: Address: Postcode:</p><p>1. Education Profile Pupil’s prior attainment:</p><p>Key Stage 1 Current Level English: Maths: Science: Reading Age: Spelling Age:</p><p>2. FAP 2015-16 Phonics Stage:</p><p>3. FAP 2015-16 Attendance Information: Current Attendance: Authorised Absence Unauthorised Absence Date of last Is the pupil expected (%) (%) (%) Attendance: to attend 5 full days/week? Yes / No If no, please provide further details of part- time timetable, including length of part-time timetable EWO Involvement Yes / No (If yes, please provide contact details) Name: Tel No:</p><p>Exclusion History:</p><p>Dates of Exclusion Length of Exclusion Reason for Exclusion From To (days)</p><p>Internal Exclusion History:</p><p>Dates of Exclusion Length of Exclusion Reason for Exclusion From To (days)</p><p>Internal Support: Support Used Yes / No Comment and Impact Adapted timetables</p><p>1:1 Sessions</p><p>Use of part-time timetable</p><p>Internal Learning Unit</p><p>Internal Exclusion</p><p>LSA Class Support</p><p>Alternative Curriculum</p><p>4. FAP 2015-16 Peer Mentoring</p><p>Use of External Mentoring</p><p>Counselling</p><p>Nurture Group</p><p>IBSP (individual behaviour support plan)</p><p>PSP (pastoral support plan)</p><p>Small Group Work</p><p>SALT </p><p>OT</p><p>School Nurse</p><p>Other Therapies eg Dramatherapy / Playtherapy / Art Therapy</p><p>Behaviour Support Team</p><p>Other</p><p>Dates of any previous schools attended:</p><p>Name of School From To Reason for Leaving</p><p>SEND [if applicable] Please provide details of the pupil’s:</p><p>Primary Need</p><p>Secondary Need</p><p>Tertiary Need</p><p>IEP Yes / No (If yes, please attach) ,. Does the pupil have a specific diagnosis? Yes / No 5. FAP 2015-16 (e.g. ADHD, ASD, Epilepsy, Dyslexia)</p><p>Does the pupil have a Risk Assessment in place? Yes / No</p><p>Has an EHCP been requested? Yes / No Date of submission: Status:</p><p>2. Social Profile Is the pupil / family open to social care? Yes / No (if yes, please provide contact details)</p><p>Name: Tel No:</p><p>Does the pupil have a CAF? Yes / No (if yes, please provide contact details)</p><p>Name: Tel No:</p><p>Is the pupil on the Child Protection Register? Yes / No </p><p>Known Issues Support provided by School</p><p>Family Overview (i.e. Position of child in relation to siblings, parental details etc)</p><p>Other Agency Involvement (complete all that apply):</p><p>Current Expired Contact Name Email EWS</p><p>CAMHs</p><p>Ed Psyc</p><p>SALT</p><p>OT</p><p>Behaviour Support </p><p>6. FAP 2015-16 Team Other (state) (See below)</p><p>Current Status:</p><p>Does the Pupil fall in to a vulnerable group? Yes / No (if yes, tick all that apply)</p><p>Children Looked After □ Traveller Child □ Child of asylum seeker □</p><p>Young carer □ Teenage parent □ School refuser □</p><p>Young offender □ Eligible for FSM □ EAL □</p><p>Checklist</p><p>These must be included within the referral documents: please tick to confirm</p><p>Pastoral Support Plan Completed referral form SIMS attendance record Most recent school report CAF Behaviour log</p><p>The following should be included if applicable</p><p>Individual Education Plan (IEP) Statement of Educational Needs Educational Psychologist Report Education, Health and Care Plan Statement Review EHCP Request Risk Assessment Active PSP</p><p>3. Panel Decision</p><p>Which of the following issues currently affect this pupil which, in your opinion, means they fall within the Fair Access protocol? (Please tick box and attach appropriate reports). Complex Issue Cases (CIC) Homeless Children with unsupportive family backgrounds Moved between a number of schools in Croydon or other boroughs Permanent Exclusion previously or currently Children without a school place and a history of serious attending the short stay school (PRU) attendance problems At risk of Permanent Exclusion/Managed Move Out of education for more than 1 school term (includes movers in and returnees from EHE) Traveller Children of refugees and asylum seekers not in accommodation centres. Withdrawn by parents following fixed term exclusion and unable to find a school place</p><p>7. FAP 2015-16 Type of provision/assessment Please Placement Agreed Support costs tick Please tick  Placement at mainstream Short stay School costs school school (PRU) Support  Respite place in short stay school (PRU)  Alternative Provision  Other (please elaborate)</p><p>Signed by Chair of panel ………………………………………………… Date: ………………………………………………….</p><p>Please return completed form to: [email protected]</p><p>8. FAP 2015-16 </p>