Referrals Student Name UPN No. Date of Birth Gender Current School Year Ethnicity Student Address Phone Email First Language CTF Available? Yes No Other Spoken Languages SEND Details Interpreter Required? Exam Access Arrangements Religion Free School Meals Yes No Student Presenting Needs Ex-offender Mental Health Drug Use CLA (LAC) Young Parent EHCP in Place Excluded from Mainstream Lives with Single Parent Victim of Domestic Violence Homeless (including sofa-surfing) Placement Request Details Respite (less than one full term) Long-term Enrolment Status at TWT Details (DfE definitions only please) Name Contact Phone Email Title First Name Surname Relationship to Student Email Address Landline Phone Mobile Phone Contact Issues to be Aware of (work patterns etc.) Title First Name Surname Relationship to Student Email Address Landline Phone Mobile Phone Contact Issues to be Aware of (work patterns etc.) In line with KCSiE 2018, if you are only able to provide one (1) parent/ carer contact for the learner, please detail reason: Current/ Last School /Provision Attended Date Last Attended Attendance at Last School Attended (0% if NEET or unknown) Authorised Absence (0% if NEET or unknown) Unauthorised Absence (0% if NEET or unknown) Is the Learner on a school role? Yes No If ‘yes’ to school role, which school? Reason for Referral, and Summary of Key Incidents (including fixed-term exclusions) Services Involvement YOT Police CAMHS Social Services Education Psychology Other Details (including key contacts) Does the learner have a CAF? Yes No If yes, please give details, including contact information, for all involved Is the learner a LAC (CLA)? Yes No If yes’, please give details of borough, key contact names, emails, and phone numbers: Are there any Safeguarding concerns around the learner (including peer-on-peer abuse) that we need to be aware of: Yes No If yes’, please give details Academic Subjects Studied Mathematics English Language English Literature Science Humanities (please detail) The Arts (please detail) Most recent major assessment point data (for GCSEs, please use grades & percentages, and for Functional Skills/Entry-Level, please use percentages) or learner subject narrative. If the above Academic Subjects and Levels table has not been completed, please provide a reason (for example ‘learner has been NEET for x months/ years/ etc.) Please provide contact details for who will be making placement payments (name, email, work telephone number, etc.). Describe the foreseeable risks (physical assault/absconding/ verbal aggression, etc.). Have they threatened it or actually done it? Who is affected by the risk? In which situation does the risk usually occur? How likely is the risk to arise? If the risk arises, who is likely to be hurt? (Student, Other Students, and/or Adults) What kinds of injuries or harm are likely to occur? How serious are the adverse outcomes? (On a scale of 1-5 with 1 being minor adversity and 5 being significant safety risks) 1 2 3 4 5 Which de-escalation strategies are most effective? After a crisis how do they calm down best and with whom? Are they able to take responsibility, and discuss issues later? Yes No Declaration I confirm that the information provided is accurate and true. Full Name Date Form Completed Submit
