School Referral Form

Full name of Child

Child's D.O.B

Year group

School Name

School Address

Named School Contact

SENCo name and contact details

Is the child on roll at your school?

Yes No

Does the child have an EHCP?

Yes No

Does the child currently have a primary diagnosis

Does the child have any medication conditions we need to be aware of

Is the Local Authority aware of and in agreement with this referral?

Yes No In Process

Please describe the primary reasons for referral to our sensory provision

Are there behaviours of concern?

Yes No

If yes, please describe (frequency, severity, context)

Is the child currently subject to:

Child in Need plan Child Protection plan Looked After Child (LAC) Team Around The Family (TAF/EH)

Are there any safeguarding concerns we should be aware of?

Proposed start date:

Frequency and duration of sessions (we offer 2 and 3 hour slots but longer sessions can be discussed)

Parent/carer consent obtained

Yes No In Progress

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