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Referral Form

During your time at the centre, you may be introduced to our members of staff who will support you throughout your time.

For the staff to support all your learning needs, please complete the questions below. This valuable information, unique to you, will allow all relevant staff members to understand you and your learning needs better.

Student Name

Learner Details 

Referral Details
Please confirm that the school have carried out identification checks on the referred young person.*
Program you are looking for: (please choose any or all)
Parental contact?
Has funding been agreed prior to referral form being completed. (Please note) We are only able to confirm start date/hold a place once you have confirmed funding has been agreed.

Communication and interaction



A child/ young person with communication and interaction needs will have greater difficulty then peers with the following:


Listening and attention:

Listening actively in a small group or whole class.
Sustaining concentration in a small group or whole class.
Listening to an instruction whilst carrying out a task.
Focussing independently on a adult initiated task (KS1-5mins, Y3/4- 10 mins, Y5/6 -20mins, Y7-11 work independently).

Expressive Language:


Articulating words clearly (they may use gesture more than their peers.
Recalling known words easily in conversation.
Retelling or describing a sequence of events.
Using language to express thoughts and ideas clearly.
Making themselves understood (may lead to frustration or withdrawn behaviour).
Making needs and wants known appropriately.
Constructing sentences verbally.
Organising spoken and written language coherently.
Communicating effectively in a range of social situations.

Understanding and Processing:


Recalling spoken information, e.g. remembering information, following the sequence of story.
Following instructions.
Processing spoken information and instructions in a timely manner.
Comprehending text that they are able to read.
Understanding abstract terms or concepts, e.g., time, space, quantities at an age-appropriate level.
Understanding timetables and sequences at an age-appropriate level.
Understanding and using sarcasm, idioms, and jokes at an age-appropriate level.

Interaction and communication:


Interacting appropriately with others, understanding the accepted rules of social interaction.
Joining in with group and whole class activities.
Understanding the social rules of group work.
Taking turns in engaging in a 2 way conversation with a familiar adult or peer (Primary).
Altering what they say depending upon who they are talking to (secondary).
Sharing resources, e.g., books, games, learning equipment.
Understanding that communication is a shared process, by seeking the attention and response of other.
Interpreting non--iteral Language e.g., understanding simple idioms.
Establishing and maintaining appropriate friendships.
Making a choice when given a limited range of options.
‘Reading’ the physical clues of non verbal language, e.g. facial expressions, gestures.
Knowing what to do at unstructured times of the day e.g. break times and transitions.
Managing changes in routine.

Self - management


Managing stresses, anxieties and frustrations.
Establishing a positive self-image.
Managing sensory responses (they may be over or under sensitive).
Being organised for learning.
Getting to where they need to be next (Secondary)
Managing homework and exam revision (Secondary)

Cognition and Learning

Speaking and listening:


If the child/young person needs support for speaking and listening

Literacy:


If the child/young person needs support for literacy.

Mathematics:


If the child/young person needs support for maths .

A child/ young person with cognition and learning difficulties will have greater difficulty peers with:


Active Listening.
Sustaining attention to complete a task.
Shifting attention to a new task.

Skills for Learning:


Understanding the point of a task.
Applying past experience.
Planning how to approach a task.
Having flexibility in problem solving.
Self-help and organisational skills.
Transferring and applying learning to new situations.

Approaches to learning:


Working independently.
Seeking and accepting support appropriately.
Persistence.
Task Completion.
Resilience / response to challenge.
Self confidence.
Motivation and engagement.

Memory and retention:


Remembering recent information and information and instructions.

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