1Page 1 2Page 2 3Page 3 4Page 4 5Summary Progress About this referral Type of referral Traded (Dyslexia Assessment) Traded (Access Arrangements) Universal (Primary/Early Years) Universal (Secondary) Please provide details of any pre-assessment screening you have completed (e.g. Name of screener, date completed, outcome) Please upload screener results for traded referrals (optional) To upload multiple files, hold 'Ctrl' (Windows) or 'Cmd' (Mac) when choosing files to upload. Which Primary SEND Support Partnership (PSSP) does your school belong to? -- Please Select -- AV1 AV2 CN1 CN2 CN3 E1 E2 E3 SC1 SC2 SC3 S1 S2 Pupil eligibility criteria Support for pupils can only be accessed if you have considered all the statements below and at least one is applicable to the pupil: (please choose all that apply) The pupil has a complexity of needs which significantly impacts on one or more areas of progress (in relation to the Four Broad Areas of Need). Having implemented the Graduated Approach and well-founded, consistent interventions for more than one term, you continue to have concerns about the pupil’s progress from their baseline. The pupil is unable to consistently access a curriculum and make expected progress from their baseline (including classroom, small group and individualised curriculums) – even with additional adult support. The pupil’s presentation in the classroom is inhibiting their learning despite application of the Graduated Approach. The pupil significantly struggles in other areas of school life (e.g. during unstructured times) and continues to do so despite application of the Graduated Approach. If the pupil has had support from other specialist services, you are able to evidence the implementation of recommendations within expected time scales and there are still ongoing concerns. The pupil is on a reduced timetable and their time in school is not increasing, despite application of the Graduated Approach. For EAL pupils – you can evidence that lack of progress is not because of language acquisition, but of underlying SEND (e.g. EMTAS First Language Assessment, NASSEA assessment). The pupil has below 90% attendance. Please consider and explain why you are sure that a lack of progress is not a direct result of their attendance issues. SENDCO details School name SENISS Specialist Teacher name SENDCO name SENDCO email address Contact number Landline numbers must include area code. Class teacher name No information is required, please proceed to the next page. Pupil details Name of pupil Date of birth Day Month Year To enter an address outside the Liverpool boundary, use the 'enter address manually' option below. Address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Year group -- Please Select -- Nursery Reception Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 Year 13 Ethnicity -- Please Select -- NOBT - Information not yet obtained BAFR – African AOTH - Any other Asian background BOTH - Any other Black background OOTH - Any other ethnic group MOTH - Any other mixed background WOTH - Any other White background ABAN – Bangladeshi BCRB – Caribbean CHNE – Chinese WROM - Gypsy / Roma AIND – Indian APKN – Pakistani REFU – Refused WIRT - Traveller of Irish Heritage MWAS - White and Asian MWBA - White and Black African MWBC - White and Black Caribbean WBRI - White British WIRI - White Irish Home language Previous schools/settings details Is the child: Looked After Child (LAC) Early Help Child in Need (CIN) Child Protection None Attendance year to date Have there been any fixed term exclusions? Yes No How many exclusions has the pupil received? (number of incidents) Is this pupil ‘at risk’ of permanent exclusion? Yes No Is the pupil currently on a reduced timetable? Yes No Please provide details of their reduced timetable Upload timetable (optional) Secondary Only Does the pupil have an EHCP? Yes No Application submitted - awaiting outcome Are they in receipt of High Needs Funding? Yes No What is the pupil's primary need? Cognition and Learning Communication and Interaction Social, Emotional and Mental Health Sensory and/or Physical Needs Does this pupil have a formal diagnosis of any of the following? (Please choose all that apply) ASD ADHD ADD Dyspraxia Dyslexia Dyscalculia Hearing Impaired Visual Impaired MLD None Other If 'Other' please specify Is the pupil known to any other professionals? None Educational psychologist Occupational Therapy Speech and Language Therapy Mental Health Services (CAMHS, YPAS etc) Social Care Community Paediatrician Neurodevelopmental Pathway Behaviour Intervention Team (BiT) Primary Other If 'Other' please specify Please upload appropriate reports for option chosen (optional) To upload multiple files, hold 'Ctrl' (Windows) or 'Cmd' (Mac) when choosing files to upload. No information is required, please proceed to the next page. Concerns / Exam Arrangements Which exam access arrangements does the student currently use? 25% extra time Reader Scribe Reading pen/computer reader Laptop Which area of cognition is a concern? Processing speed Memory Reading Writing Spelling Upload Form 8 for the student (optional) Current performance Which stage is the pupil at EYFS KS1-2 KS3-4 Post 16 In which of these areas is the pupil experiencing difficulties? Communication & Language Physical Personal Social & Emotional Curriculum (Literacy/Maths) Other If 'Other', please specify Please indicate pupil's performance in the following areas (in line with their individual expected levels of progress) Reading Below expected Expected Above expected Writing Below expected Expected Above expected Spelling Below expected Expected Above expected Maths Below expected Expected Above expected History Below expected Expected Above expected Science Below expected Expected Above expected Please indicate pupil's performance in the following areas Relationship with peers Below expected Expected Above expected Relationship with adults Below expected Expected Above expected Organisation / Time management Below expected Expected Above expected Attention / Concentration Below expected Expected Above expected Self regulation Below expected Expected Above expected Further information The nature of your concerns will be the specific focus of the assessment / observation/ visit. Please comment on: The specific concerns you want addressed through this referral If the pupil’s difficulties are more evident at specific times of the day / in specific lessons What support you would like from SENISS Nature of your concerns What have you tried already and what was the impact of this? (specific approaches, interventions or resources used) Please provide any other information that may also be impacting on the pupil (optional) (e.g. Change to family circumstances/Bereavement/Health) Upload pupil passport No information is required, please proceed to the next page. Pupil & Parent/Carer Voice Your answer to these questions will help the SENISS teacher understand the holistic needs of the pupil and will help them to better prepare for the visit. Pupil Voice - What are your strengths and interests in school? Pupil Voice – What is working well for you in school? Pupil Voice - What are the challenges you are facing in school? (This can include specific subjects, skills or even times of day or relationships etc) Parent/Carer Voice - What are your child's strengths and interests in school? Parent/Carer Voice - What is going well for your child in school? Parent/Carer Voice - What are the challenges faced by your child in school? (This can include specific subjects, skills or even times of day or relationships etc) Parental consent Prior to sending the completed referral form, it is the responsibility of the school to ensure the person with parental responsibility has agreed with the content of the referral and understands what support is being requested from SENISS. School have gained consent from the pupil's parent/carer? Yes No You must obtain parental consent to submit this referral. Name of the parent/carer who has given consent Parent/Carer telephone number Landline numbers must include area code. Parent/Carer email address The parent/carer has given permission for Liverpool's Outreach Services to work with their child Yes No The parent/carer has given permission for Liverpool Outreach Services to discuss their child in a virtual meeting (if necessary) Yes No The parent/carer has given permission for relevant information about their child may be shared with other professional agencies in order to help to meet the needs of their child. (Please use the 'Other' box to list any services which you DO NOT wish information to be shared with) Yes No Other If 'Other', please specify Disclaimer By submitting this form, you acknowledge that the details contained within this referral form have been discussed with the pupil, parents/carers and any other relevant stakeholders, and the appropriate level of parental consent has been obtained. It is the responsibility of the professional completing this referral to ensure that all relevant information about SENISS involvement has been shared and parental consent obtained. SENISS are not liable for to any consequences for the sharing of information without parental consent. Confirmation I confirm that this information is accurate to the best of my knowledge No information is required, please proceed to the next page. Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page Loading form summary...