Refer a child for Cheshire School
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Referring Body
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Parent/Carer
School
Medical Specialist
Name of Referring Individual
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First
Last
Name of Referral Agency/Organisation
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Email
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Phone
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Student Name
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First
Last
Date of Birth
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Day
Month
Year
Current Year Level
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Home Address
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Street Address
City
State / Province / Region
ZIP / Postal Code
Parent/Carer Contact Details
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Please click the + button to add a second parent/carer
Name
Phone
Email
Relationship
Add
Remove
Current School
Diagnoses
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Yes
No
Please provide a brief outline of diagnoses
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Medication taken
Reasons for Referral
Concerns at School / Home:
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In what ways is it anticipated that a placement at Cheshire School will assist the student and the family?
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Have any suspensions or expulsions occurred?
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Yes
No
Please outline the behavioural consequences of the suspension or expulsion
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Please outline the staged response the school has taken to help the student and the family:
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Support Agencies
Is the student currently supported by any of the following:
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Paediatrician
Psychologist
Psychiatrist
Occupational Therapist
Speech Pathologist
Other
Support Planning
Is the student able to engage successfully in the:
Classroom?
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Always
Frequently
Occasionally
Seldom
Never
Playground?
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Always
Frequently
Occasionally
Seldom
Never
Home?
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Always
Frequently
Occasionally
Seldom
Never
Community?
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Always
Frequently
Occasionally
Seldom
Never
Are there special arrangement in place to support this student’s needs when in the:
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Please tick whichever applies
Classroom
Playground
Home
Community
Please outline the special arrangements and support in place:
Does the student have a Behaviour Support Plan/Safety Plan?
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Yes
No
Does the student have an Individual Learning Plan?
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Yes
No
Does the student have a Student Support Group (SSG)?
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Yes
No
Does the student have a Mental Health Plan?
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Yes
No
Eligibility Assessment
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• 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.
I confirm the above eligibility criteria can be met.
Acknowledgement of Consent
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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.
I agree
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Enquire about our Therapy Services
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Name
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First
Last
Phone
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Email
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Services of interest
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Speech Pathology
Occupational Therapy
Psychology
Physiotherapy
Music Therapy
Play Therapy
Behaviour Analysis
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Dietitian
Specialist Teacher
Therapy Assistant Program
Closest Location
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Glen Waverley
Officer
Williamstown
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