Cheshire School Referral
Name of Referring Individual
Student Name
Street Address
Parent/Carer Contact Details 1
Parent/Carer Contact Details 2
Parent/Carer Contact Details 3
Parent/Carer Contact Details 4
Diagnoses
Reasons for Referral
Have any suspensions or expulsions occurred?
Support Agencies
Is the student currently supported by any of the following
Support Planning
Is the student able to engage successfully in the
Classroom?
Playground?
Home?
Community?
Are there special arrangement in place to support this student’s needs when in the
Does the student have a Behaviour Support Plan/Safety Plan?
Does the student have an Individual Learning Plan?
Does the student have a Student Support Group (SSG)?
Does the student have a Mental Health Plan?
Eligibility Assessment

• Student is of age eligible for primary school.
• Student is experiencing significant social, emotional and/or behavioural difficulties which place them at risk of disengagement within the mainstream educational setting.
• Student has speech and language skills within the normal range.
• Student has a full scale IQ of 80 or more.
• Student is unlikely to cause significant or persistent harm to themselves and others.
• Student exhibits positive indicators of the ability to sustain changes made and to reintegrate into mainstream school following placement at Cheshire School.
• Parents, guardians and carers are willing to support school policies and procedures and will be positively and actively responsive to working with staff to support behavioural change.

Acknowledgement of Consent

I have received consent in writing from the parent, guardian or carer of the student named in this referral which allows for mutual exchange of information between the above-mentioned school and Cheshire School. I agree that the consent received from the parent, guardian or carer acknowledges that the authority will remain in place for the duration of the student’s involvement with Cheshire School.