Medical Alternative Provision

School Referral Form

This form should be used to refer a child or young person who has significant health needs, which are temporarily preventing them from accessing education at their home school. The referral must be completed by the school and include evidence from an appropriate clinician.

A referral will not be considered if the head teacher/principal and parent/carer have not signed to indicate their agreement (Sections 2 and 3).

Section 1 – for schools to complete
1.1.	Pupil details	
Surname		Forename		
Date of Birth		Gender		
Address	

	
Post code		UPN		Current Academic Year		
FSM	Yes	☐ 	No	☐	

1.2.	Parent/Carer details	
Contact 1	Contact 2	
Full name including title		Full name including title		
Relationship to pupil		Relationship to pupil		
Home address
(if different to pupil)

		Home address
(if different to pupil)		
Post code		Post code		
Home telephone		Home telephone		
Mobile		Mobile		
Email		Email		

1.3.	Current school/setting details	
Referring school		School contact and role		
Contact tel. 		Contact email		

1.4.	Outline of pupil’s diagnosis and reason for referral	
Mental Health need	Yes	☐ 	No	☐	Physical health need	Yes	☐ 	No	☐	
Details: 

	

1.5.	Other professionals involved: what actions are currently in place to support the pupil? (Please provide as much detail as possible)	
Agency	Lead professional
(name and role)	Nature of intervention	Contact details	
Paediatrics				
Solar				
Educational Psychology				
Engage				
SISS				
Social Services				
Young Carers Service				
Youth Offending Service				
Other				

1.6.	Intervention/Actions taken by school to support the pupil’s education in the home school	
Intervention/Action	Date and Duration	Outcome	

			

1.7.	Assessment results	
	English	Maths	Science	
Key stage 1				
Key stage 2				
Key stage 3				

1.8.	Key stage 4 courses being followed (if appropriate)	
Subject	Awarding Body	Qualification	Current Grade	Predicted Grade	
English Language					
English Literature					
Maths					
Science					
Other					

1.9.	SEND details	
SEN register?	Yes	☐ 	No	☐	
EHCP applied for?	Yes	☐ 	No	☐	Date: 	
EHCP draft?	Yes	☐ 	No	☐	Date: 	
EHCP final?	Yes	☐ 	No	☐	Date:	

1.10.	Risk Assessment and Safeguarding	
	(0 = Unlikely, 1 = Possible, 2 = Probable, 3 = Certain)	
Truanting lessons	0	1	2	3	
Absconding from school site	☐	☐	☐	☐	
Persistent refusal to follow instructions	☐	☐	☐	☐	
Verbal aggression towards peers	☐	☐	☐	☐	
Verbal aggression towards adults	☐	☐	☐	☐	
Physical aggression towards peers	☐	☐	☐	☐	
Physical aggression towards adults	☐	☐	☐	☐	
Bullying peers	☐	☐	☐	☐	
Inappropriate sexual behaviour towards others	☐	☐	☐	☐	
Dangerous behaviour 	☐	☐	☐	☐	
Confidential child protection (information available on request)	☐	☐	☐	☐	

1.11.	Behaviour
	(including any isolation, internal exclusion and fixed term exclusion information)	

	

Section 2 – Headteacher/Principal to sign
Headteacher (name)		
Signature		
Date		

Section 3 – Parent/Carer to sign
Parent/Carer (name)		
Signature		
Date		

Section 4 – Health evidence. School to provide from at least one of the following:

Senior clinical psychologist		☐ 
Consultant psychiatrist		☐ 
Associate specialist psychiatrist	☐ 
Community paediatrician		☐ 
Hospital consultant			☐ 

Section 5 - School evidence (include copies of all relevant documentation)

Last school report			☐ 
EHCP (draft/final)			☐ 
Attendance record over one year	☐ 

Please ensure all sections are completed in full. If incomplete referrals are submitted, this may result in a delay whilst the Medical Alternative Provision Service awaits the additional information.

CHECKLIST

Section 1
1.1.	Pupils details					☐ 
1.2.	Parent details					☐ 
1.3.	Current school details				☐ 
1.4.	Diagnosis/reason for referral			☐ 
1.5.	Professional involvement			☐ 
1.6.	School interventions				☐ 
1.7.	Assessment results				☐ 
1.8.	Key stage 4 courses (if applicable)		☐ 
1.9.	SEND						☐ 
1.10.	Risk assessment and safeguarding		☐ 
1.11.	Behaviour					☐ 
Section 2
Headteacher/Principal signature			☐ 

Section 3
Parent/Carer signature				☐ 

Section 4
Appropriate health evidence				☐ 

Section 5
School evidence					☐ 

Send completed forms and scanned documents to echn@solihull.gov.uk

Alternatively, your form can be posted to:
Medical Alternative Provision
Solihull Alternative Provision Service
3rd Floor, East Wing
Council House
Manor Square
Solihull
West Midlands
B91 3QB