LEARNING SUPPORT REFERRAL FORM
Section 1
Sub-School:
*
Please Select
Primary
Secondary
Student Information
Full Name:
*
Year Level/Class:
*
Date of Birth:
*
-
Day
-
Month
Year
Date
Referring Teacher Name:
*
Referring Teacher Email:
*
example@example.com
Date of Referral:
*
-
Day
-
Month
Year
Date
Section 2 - (Mandatory to complete before submitting the referral)
Parent communication recorded on SEQTA:
*
Please Select
YES
NO
Consent for screeners received verbally:
*
Please Select
YES
NO
SEQTA notes on adjustments recorded:
*
Please Select
YES
NO
Does student receive NDIS funding:
*
Please Select
YES
NO
Does student receive external specialist support:
*
Please Select
YES
NO
Section 3 - Referral Information
Areas of Concern (select all that apply)
*
Reading/comprehension
Writing/Spelling
Speech/Language difficulties
Communication - receptive and/or expressive
Processing/memory/recall
Sensory processing
Numeracy
Attention/focus/Organisation
Fine Motor/Gross Motor
Physical - Health/Eyesight/Hearing
Behaviour/ Social/ emotional
Mental health concerns (anxiety, depression, trauma etc)
Neurodiversity (ASD, ADHD, ADD etc)
Absenteeism and/or school refusal
New enrolment
EAL
Gifted/Talented
Wellbeing concerns
Screeners required
Other
Any additional information (optional)
Student Strengths:
*
Student Challenges observed:
*
Upload Supporting Evidence:
Results in relevant class assessments
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Dated Student work sample
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PAT results/Essential Assessments/ Marks book
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Section 4 - For LS Department to complete
Date Received:
-
Day
-
Month
Year
Date
Action Taken:
Follow-up plan:
Submit
Should be Empty: