Newts

Referral Form

Please complete all sections of this form as fully as possible.

Once the form is reviewed, NEWTS will contact you.

Please forward any relevant copies of reports or samples of work that support this referral to info@newts.uk

Confidential reports will be electronically deleted or shredded after use.

Referrer Details

Person making the referral and position*

Email address*

Telephone number*

Name of Individual being referred*

Date of referral*

Individual Details

Date of Birth*

Age

Gender

MaleFemaleOther (please specify)

Other

Looked After Child (LAC)

YesNo

Current year in education

Current Educational Situation

Education History/Schools or Provisions attended

First language

English as an Additional Language (EAL)

YesNo

Approximate School Attainment in English

Reading

Writing

Spelling

Approximate School Attainment in Maths

Number calculation

Maths Reasoning

Or overall attainment

Current Concerns

The following information is used to help triage you to the most appropriate service/professional. Please select any areas that may be a current concern or have been investigated.

Areas of Concern

Attention / Concentration issuesMemoryVisual DisturbanceGross Motor Co-ordinationFine Motor Co-ordinationAnxietyMental Wellbeing IssuesSpeech and Language issuesAttachment Issues / TraumaEating difficultiesMaths difficultiesMaths AnxietyBehavioural DifficultiesOther

If 'Other', please provide details

Existing Diagnoses

Is there a diagnosis of any of the following? Please indicate date if known. Reports will be requested.

Diagnosed Conditions

Autistic Spectrum Condition (ASD/ASC)Attention Deficit Hyperactive Disorder (ADHD)DyspraxiaDysgraphiaDyscalculiaAttachment ConditionsAnxiety ConditionsSpecific Language DisorderDevelopmental Language Delay (DLD)Hearing (Does the child have a Teacher Of the Deaf?)Physical ConditionMental Health ConditionOther

Please provide details of any diagnoses including dates and who diagnosed

Accessibility and Other Needs

Accessibility Requirements

Needs wheelchair accessAccess to a disability toilet (unfortunately, we cannot provide any intimate toileting care)

Allergies

Please detail any other information you feel it may be beneficial for us to know

Declaration

Signature*

Sign above using finger or stylus

Print name*

Date*

Relationship to individual if under 18 years

This form is provided by NEWTS