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Referrals
JEP Youth Engagement
Referral Form
School Referrer Details
Host Setting Name
Host Setting Locality
Name of Lead Professional for Referral
Lead Professional Email Address
Lead Professional Contact Number
Host Settings's Main Email Address
Date of Referral
Pupil Information
Surname
Forename(s)
Date of Birth
Age
Year Group
Main Home Address
Who Does the Pupil Live With
Other Home Address(if applicable)
Ethnicity
First Language
Pupil Premium (Y/N)
Free School Meal (Y/N)
Parent/Carer Details - 1st Contact
Name
Relationship to Student
Address
Home Telephone
Mobile
Work Number
Place of Work
Unusual Work Hours
Email Address
First Language
Parent/Carer Details - 2nd Contact
Name
Relationship to Student
Address
Home Telephone
Mobile
Work Number
Place of Work
Unusual Work Hours
Email Address
First Language
Parent/Carer Details - 3rd Contact
Name
Relationship to Student
Address
Home Telephone
Mobile
Work Number
Place of Work
Unusual Work Hours
Email Address
First Language
Reasons For Referral (Tick All That Apply)
Attendance
Risk of Permanent Exclusion
Social and Emotional Health
Behaviour
Incidents at School That Have Given Rise to Concern (Tick All That Apply)
Physical Assault Against Adult (PA)
Physical Assault Against a Pupil (PP)
Verbal Abuse/Threatening Behaviour Against Adult (VA)
Verbal Abuse/Threatening Behaviour Against Pupil (VP)
Bullying (BU)
Racist Abuse (RA)
Sexual Misconduct (SM)
Drug and Alcohol Related (DA)
Damage (DM)
Theft (TH)
Persistent Disruptive Behaviour (DB)
Inappropriate Use of Social Media or Online Technology (MT)
Use of or Threat of use of an Offensive Weapon or Prohibited Item (OW)
Wilful and Repeated Transgressions of Protective Measures in Place to Protect Public Health (PH)
Abuse Against Sexual Orientation and Gender Identity (LG)
Abuse Relating to Disability (DS)
Aims of Placement
Aim 1
Aim 2
Aim 3
Predicted Length of Placement
Safeguarding
Social Care Involvement(Y/N)
Child Protection (Y/N)
Child in Need (Y/N)
Child Looked After (Y/N)
Early Help Assessment (Y/N)
Does The Pupil Have Any Caring Responsibilities?
Agency Involvement
CAMHS
Educational Psychology
School Nurse
Family Support Worker
Youth Offending Team
Behaviour Support Service
Virtual School
Early Intervention Team
Other
Medical Needs
Hearing
Vision
Speech & Language
Specific Learning Difficulties
Autism Spectrum Disorder
ADHD
Allergies
Other
SEN Information
EHCP
School Support
ILP/PEP
Date of Last SEN Meeting
Date of Last Review
What is/are the pupil’s primary need(s)?
Communication and Interaction
Cognition and Learning
Social, Emotional and Mental Health
Physical
What access arrangements does this young person require?
What Provision Have You Identified That Would Match The Needs of The Pupil?
Secondary/Post 16
Academic:
Our curriculum, rooted in English & Maths, adapts the National Curriculum to meet individual needs, fostering a love of learning through personalised, flexible teaching beyond a typical mainstream offer
Blended:
Starting with each learner’s specific needs and strengths, the blended pathway combines elements of both our Academic and My Future
Enrichment - MY Future (Mentoring Your Future)
Designed to raise aspirations and promote a sense of personal pride in achievement that includes a wide range of enriching experiences and opportunities
Primary
Pioneer:
A blend of academic curricula for young people working at or below ARE, with additional pastoral support and intervention elements according to need
Enrichment/Life Skills – Adventurer:
A non-academic curriculum for young people designed to raise aspirations and promote a sense of personal pride in achievement that includes a wide range of enriching experiences and opportunities
Primary & Secondary
Forest School:
Through guided activities like outdoor craft and tending to the JEP Allotment, our young people build resilience, confidence and independence through interaction with the natural world around them
Please identify the days, number of hours, time of day and group size.
Example sessions times are as follows:
Maximum 16 hours per week.
Secondary 9-12/1pm or 2-5pm
Primary 9-12/12.15pm or 2-5pm
Education Details - Academic Attainment
English Reading Grade
English Reading Exam Board
Comments (English Reading)
English Writing Grade
English Writing Exam Board
Comments (English Writing)
Phonics Screening Grade (if applicable)
Phonics Screening Exam Board
Comments (Phonics Screening)
Maths Grade
Maths Exam Board
Comments (Maths)
End of KS1 Results (if applicable)
KS1 Exam Board
Comments (KS1)
End of KS2 Results (if applicable)
KS2 Exam Board
Comments (KS2)
Option Subjects Grades
Option Subjects Exam Boards
Comments (Option Subjects)
Attendance & Behaviour Overview
Last Year Attendance %
This Year Attendance %
Number of Days of Fixed Term Exclusions
Reasons For Exclutions
Additional Information
Please explain what the pupil’s strengths are.
Please explain any barriers to the pupil’s learning.
Please explain what is currently happening in the pupil’s life and any historical context that should be considered/known.
Please list any strategies in school/provisions that have had a positive impact.
Thank you! Your referral has been received!
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