Children’s Services and Skills Directorate
SEND 0-25 Service
Specialist Inclusion Support Service
Social, Emotional and Mental Health Team

REFRESH SISS SEMH Nurture Provision                         
Pupil Referral Form
Before completing this form, you will have discussed this referral with your SEMH Advisory Teacher. Please ensure you have read both the ‘Pupil Profile’ information and the Service Level Agreement and completed the checklist. 	
Pupil Details	
First Name	 	Last Name	 	
Date of Birth	 	Gender	 	

Address

	
Parent /Carer's Name		Tel no. & email address		
Setting/School	 

	Year Group		
Name of Referrer		Tel no.  & email address		
Medical conditions/allergies	

Class Teacher – name & email address	Name

Email	
Other professionals involved	
Role
	Name/Organisation	Current Involvement 	Contact Details	
SEMH Advisory Teacher
				
Educational Psychologist
				
Speech and Language Therapy
				
Communication and Learning Advisory Teacher 				
Occupational Therapist
				
Childrens Social Care
				
Paediatrician / Health
				
Other
				
Academic Attainment levels (please include recent assessment data e.g. phonics screening check results, reading age and an indication of which national curriculum year group level the pupil is working within)		
Reading		
Writing 		
Maths		
Other relevant assessments	
	
Family background information (most relevant and up to date)	

	
Reason for referral/description of needs: (e.g. social skills, managing emotions, managing friendships, self-esteem, anxiety, impact of lockdown)	

	
What is working well?
(what has been tried in school - please include pupil strengths and interests)	What is the desired outcome of the placement?     
(what do you want to see when pupil returns)	

Parental Consent
 Any information that you provide will be used by SISS to help us tailor services for your child. Your information will be treated as confidential, and stored in a secure way. It will only be shared with other council services and partner organizations to ensure our records are kept accurate.   The staff from the team working with your child will report on assessment and or intervention findings and discuss with you and your child’s school the action and support which will need to follow.
We may also need to share your information for the prevention and detection of fraud and/or other crimes or as the law requires.  For further information about how we use your information please refer to the Council’s Privacy Statement on www.solihull.gov.uk.
Your records will be kept for 25 years for audit purposes and in the event we need to provide information about the service you have received.                                           
                                                                                                                                                                               Yes		No

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•	I confirm I understand why you want my information and I have had the opportunity    to consider this. 

•	I agree that the information will be shared with other professionals who are already involved with my child, or other agencies that may become involved in the course of any support offered to my child.  This will be done in accordance with Solihull’s MBC Information Sharing Protocols. This will only be information that is relevant and necessary and will only be shared with people who need that information at that time. 

•	I understand I can opt out and withdraw my consent at any time by contacting the 0-25 Children and young People’s Service Business Support Unit on 0121 7046690 or via email at sissnurtureprovision@solihull.gov.uk.

•	I give consent for you to record and hold my information for the        
purposes explained to me. 
•	I confirm that the information contained in this form is accurate,  the
reasons for referral have been discussed with me and I am aware of the 
purpose, criteria and protocol of the SEMH Nurture provision, including the referral
and panel processes.

Name of Parent/Carer: 									 (please print) 

Signature: 								__________ Date: 			

Please attach Nurture Provision Checklist and relevant accompanying documents, including an online Boxall Profile and email your request to: sissnurtureprovision@solihull.gov.uk