School Referral form Referrer's detailsFirst Name *Last Name *Email Address *SENCO (if different to referrer)Phone NumberRole *Date of referral *Young person's detailsFirst Name *Last Name *Preferred NameDate of birth *NHS number (if known)Street Address *City *Post Code *School / ClassPhone NumberIs the young person aware of the referral? *YesNoDoes the young person consent to the referral? *YesNoPerson who holds parental responsibilityFirst Name *Last Name *Is their address different from the young person's above?YesNoStreet Address *City *Post Code *Has consent been obtained from person who holds parental responsibility? *YesNoReason for referralDoes the young person have an Education, Health and Care Plan(EHCP)? *YesNoDiagnosis (If applicable)Any known risk:GenderKnown professionals involvedIs the young person on a Child In Need (CIN) plan? *YesNoIs the young person on a Child Protection (CP) plan? *YesNoIs the young person a looked after child (LAC)? *YesNo Submit Form
