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.