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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Making themselves understood (may lead to frustration or withdrawn behaviour)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
Retaining recent learning
Physical Needs

A child/young person with a physical need may:


Move awkwardly or require aids to walk
Try to avoid or have difficulty with some practical activities
Become tired easily
Have a medical diagnosis of a physical condition which may or may not be progressive

A child/ young person with a physical difficulties may need support for some of the following:


Mobility:


Moving safely around the school
Moving around on uneven ground
Managing stairs
Accessing physical activities, e.g. using climbing frame, trike, equipment
Organising and accessing resources
To develop a sense of danger
Carrying out controlled movements, e.g. in P.E.
Carrying their bags between classes (KS 3 and 4)

Independence:


Managing eating and drinking safely, e.g., to eat without choking
Managing eating and drinking efficiently, e.g., to prevent spills when drinking to open packages
Dress, e.g., getting clothes the right way around
Getting to and using the toilet

Accessing Learning.


Attending and listening as part of the whole class or a small group
Following age-appropriate instructions
Processing and recalling information, e.g., remembering instructions, the sequence of a story
Orgaising ideas and thoughts and express them coherently
Articulating clearly and in a timely way
Being organised for learning e.g. organising equipment
Activities involving fine motor skills, e.g. holding and using a pencil, scissors or ruler functionally.
Activities that involve crossing the midline, e,g, passing an object from one side of the body to the other
Stabilising the body to participate in learning activities in sitting and standing e.g. sand tray, painting, Art, Group activities at a table in Science or D and T
Having confidence to join in with group and whole class activities

Social and emotional needs.


Managing anxiety and or frustration
Building self esteem
Sustaining learning behaviour e.g. they may show higher levels of fatigue, distractibility, of task behaviour

Secondary Only


Do you require the following:


Functional skills assessment : (please note this is at an additional cost of £250.000 for the exam)

Do you require functional skills qualification if so which do you require:

If you would like additional Functional skills tutoring, please contact our referrals team  at referrals@hitchcoxgroup.co.uk


Social Services


Social Services
Has or is the young person been on a child protection register?
Is the young person subject to TAF/CIN meetings?

Primary SEN needs


Physical health issues?
Medical diagnosis?

Secondary SEN needs


Physical Health issues?
Medical diagnosis?
Does the young person have a Health Care Plan?

Please attach.


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Student Profile

We/I agree to the following:

By ticking the boxes below, I confirm my agreement to the following statements:

The referrer will infom Orchard Therapeutic Farm of any incidents that have occored at home/ school relevant to their potential behaviours at Orchard Therapeutic Farm.*
We/ I will inform Orchard Therapeutic Farm if a child is absent on the days they are due to attend before 10am on the morning of the absent.*

Reviews


As part of our QA cylce and offer we will endeavior to attend all professional meeetings that affect the process of our young persons.

Please complete the dates below:

If applicable please indicate the next CIN/TAT review date and whether you wish for a senior member of our team to attend.

CIN or TAF ?
Do you wish Orchard Therapeutic Farm to attend?

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