Brian Jackson College
Independent Inclusion
For KS4
Referral Form
Brian Jackson College Independent Inclusion for KS4
Initial Referral Form
SCHOOL DETAILS
School
Key School Contact
Contact number
STUDENT DETAILS
Surname:
Previous Names (AKA):
Address:
First Names:
Unique Student No:
Male 
Female 
Date of Birth:
Year Group:
Ethnic Code:
Not on School Roll (CME) 
Religion:
Nationality:
Childs first language or preferred means of communication:
Immigration status: Asylum Seeking 
Refugee Status 
Interpreter/signer required for child/young person:
YES  NO 
Exceptional Leave to Remain 
Who is the student living with?
Single parent  Parents 
STUDENTS BACKGROUND
Grandparents 
Friends 
 Young Offender
 Learner with Disability
 Traveller
 At risk of exclusion
PARENT/CARER INFORMATION
Mr/Mrs/Miss/other:
Relationship to Child/young person:
Address:
Looked after child 
 Excluded
Other (please state) 
 Poor Attendee
Full Name:
CONTACT DETAILS/TELEPHONE NUMBER:
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1st Language:
Does this person have parental responsibility:
Interpreter required: YES  NO 
YES  NO  (if NO – complete below)
Name of person with Parental Responsibility and contact details:
Other significant members of the family:
HEALTH
Is the student taking any medication or have any allergies?
 YES
NO
Does the learner have any health/support needs, including mental, emotional and physical?
 YES
 NO
Is the learner currently working with any other agencies to access support with any health issues?
YES
 NO
Does the learner have any disabilities?
YES
NO
Does the learner have any special needs?
YES
NO
YES
NO
YES
NO
Is the learner currently working with any other agencies to access support with any safeguarding
Issues?
Does the learner have any caring responsibilities?
YES
NO
YES
NO
Does the learner feel safe from harm?
YES
NO
SPECIAL NEEDS INFORMATION
If yes, at what stage are they? (please tick)
School Action 
School Action + 
Is there an ILP/PEP in place?
Statement/EHCP 
Additional information attached (if required)
SAFEGUARDING
AGENCY INVOLVEMENT: please provide contact details including lead professional, actions following agency
involvement and outcomes
Education psychologist 
Actions:
Contact:
Outcomes:
Attendance and Pupil Support Service 
Actions:
Contact:
Outcomes:
Family Support and Child protection Services 
(Social Worker)
Actions:
Contact:
Mental Health Services CAMHS  CHEWS 
Actions:
Contact:
Outcomes:
Outcomes:
Health 
Actions:
Contact:
Outcomes:
YOT 
Actions:
Contact:
Outcomes:
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Other please specify:
Actions:
Contact:
Outcomes:
GENERAL LEARNER INFORMATION
Please use this box to include any additional information regarding anything that could prohibit the young person from achieving/engaging with
Learning? (eg travel, caring, responsibilities, previous negative experiences, relationship to parents etc.)
REASON FOR REFERRAL: (Nature of Concern)
ACTIONS TAKEN: (School Interventions)
OUTCOMES: (Following School Interventions)
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DAY 6 – to be completed for all permanent exclusions.
Date of permanent exclusion:
Day 6 Provision start date:
Date notified LA:
REASONS FOR EXCLUSION: Please provide FULL DETAILS of the current exclusion, i.e. what behaviour/incidents lead to this exclusion?
If a child/young person is a health and safety risk please provide contact details for a person in school who can contribute to a risk assessment.
Is a Risk Assessment required? YES 
NO 
Parent/Carer & Childs Views
Within this section schools should summarise the views of the parent/carers, (through consultation), and seek to establish the views and
concerns of the child.
CHILDS STRENGTHS/INTERESTS:
VIEWS OF PARENTS/CARERS:
VIEWS OF THE CHILD:
Please indicate the views of parents/carers:
Please indicate the views of the child:
CHILD/YOUNG PERSON INFORMATION (PLEASE COMPLETE IN FULL)
CURRENT ATTENDANCE (%)
ATTENDANCE LAST ACADEMIC YEAR (%)
Please provide a printed copy of (SIMS) data for the child’s last academic year:
Data provided YES
Reading Age:
NO
COGNITIVE ABILITIES TEST (CAT)
Test Date:
V
PLEASE PROVIDE ANY INFORMATION YOU HAVE AROUND ATTAINMENT & PROGRESS
N
NV
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ENGLISH:
MATHS:
SCIENCE:
YES
Please indicate if child is making expected progress:
IS THIS CHILD ENTITLED TO FREE SCHOOL MEALS:
DOES THIS CHILD ATTRACT PUPIL PREMIUM FUNDING:
ICT:
NO
YES
YES
NO
NO
INTERVENTIONS
USING PUPIL PREMIUM FUNDING:
LOOKED AFTER CHILDREN: (Children & young people in care)
Is this CHILD/YOUNG PERSON Looked after?
YES
NO
PEP DATE:
Has the school applied for additional LAC funding (pupil premium plus)
YES
NO
DOES THE LEARNER HAVE:
A preferred learning style?
YES  NO 
Auditory Kinaesthetic visual
A history of poor school attendance?
YES 
NO 
A noted decrease in school attendance?
YES 
NO 
Limited social skills?
YES 
NO 
Low self esteem and self confidence?
YES 
NO 
A lack of commitment to learning?
YES 
NO 
Low aspirations, or is there evidence of limited educational progress, but
Not necessarily lacking in ability?
YES 
NO
Disaffection from formal school for academic or social reasons?
YES 
NO
External factors limiting achievement?
YES 
NO 
Complex support needs eg ADHD, Aspergers?
Are they at risk?
YES 
YES 
NO 
NO 
Any other issues? (Please give details in the space below)
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To be completed for all referrals to Brian Jackson College KS4 Inclusion
Exam Entries/Courses Studied
SUBJECT
BOARD
CURRENT STATUS (i.e. work completed and
Modules taken, exam entries)
PREDICTED
GRADES
Additional Information:
What does the young person do well and enjoy?
What are the young person’s ambitions/hopes for the future?
YES 
NO 
Please specify if YES:
Are there any reasons to suggest that the young person is “a victim” YES 
And might be exploited?
NO 
Please specify if YES:
Are there other young people who s/he should not mix with?
YES 
NO 
Please specify if YES:
Is there evidence of drug, alcohol or substance misuse?
YES 
NO 
Please specify if YES:
Should reintegration seem to be appropriate in the future, will
You be prepared to readmit the young person subject to
Negotiation?
Is the young person currently enrolled in any other alternative
Provision/engagement programme/NEXUS?
YES 
NO 
Comments:
YES 
NO 
Please specify if YES:
Could the young person continue with this activity whist attending
Brian Jackson College?
YES 
NO 
Comments:
Are there any reasons to suggest that the young person might
Exploit others (bullying, intimidation, offending and so on)?
Please complete consent form
PARENTS/CARERS CONSENT TO REFERRAL AND INFORMATION SHARING WITH OTHER RELEVANT AGENCIES
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This section of the form should be completed with parents/carers.
Attendance at most of the alternative resources involves young person’s travelling to and from by public transport. Are parents/carers prepared to allow
this? Costs are usually covered.
Is the young person capable of travelling independently? YES 
NO 
Parents/carers declaration:
I agree that this referral may be made and that the information given on this form, as well as any relevant information from other sources, may
be made available to Brian Jackson College. All of the information in this referral may also be shared with other agencies. Throughout the
placement process and during the placement, additional help for my child may be provided by the school in partnership with Brian Jackson
College.
Signed:
Name (printed)
Date:
YES  NO
Has parents/carers signature been obtained and dated?
School to retain a signed copy.
HEAD TEACHERS CONSENT:
IF ON A SCHOOL ROLL – the Head Teachers agreement to the referral must be obtained.
HEAD TEACHERS CONSENT: I agree that this referral may be made and that the information given on this form, as well as any other relevant
Information from other sources may be made available to Brian Jackson College.
All of the information in this referral may be shared with other agencies involved. I agree to the funding arrangements.
Signed (or electronic signature)
Name (printed)
Has the Head Teachers signature been obtained and dated?
DATE:
YES 
NO 
Date received by Brian Jackson College:
Initial Action to be taken:
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