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Student referral
Your School
*
Forest Moor
Harrogate Grammar School
St John Fisher School
Vale of York
The Forest School
Joseph Rowntree
Springwell Harrogate
Archbishop Holgate
Rossett School
Craven PRS
Fulford School
Selby High
South Craven
St Aidans
All Saints York
Green Meadows
Harrogate High
Springwell East
Springwell North
Springwell West
Springwell South
Manor CofE, York
Strive
Parkside, Bradford
Bingley Grammar School
Your name and email
*
School DSL name and email
*
Parent/Guardian Name, Address & Contact Details
*
Student Name
Year Group
13
12
11
10
9
Number of Days
*
1
2
Days preferred
*
Monday
Tuesday
Wednesday
Thursday
Friday
Any
Medical or Learning Considerations
*
CAMHS involvement
EHCP
Takes medication
EOTAS
Autism/ ADHD spectrum
Physical Limitation
SEMH
None
What are you referring for?
*
Work experience
Work Ready Course
Box for Success
All the above
Something else
Student attitude to learning affecting engagement
*
Discipline
Confidence/ anxiety
Interaction with Students
Interaction with Teachers
Poor communication
Little empathy
Won’t take advice
Poor attendance or time keeping
Home Influences affecting engagement
*
Drugs
Alcohol
General home environment
Anti-social behaviour
Crime
Vulnerable to grooming
Lack of role models
Being a Carer
Self Harm
None
Further details or safeguarding elements
*
None
Your Signature (please type in the box)
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