Coal Clough Academy Alternative Provision Referral Form  
All sections MUST be completed before the application is processed. Failure to do so may slow down the referral.
Please note by submitting this referral form you are accepting to pay the relevant charges which apply to this pupil. 
Please return completed form to: admissions@coalclough.org				
Details of pupil
				
First Name(s) 	 	Surname		
Gender		Ethnicity		
First language		Religion		
D.O.B		Year 		
Free School Meals

If Yes, date began	Yes/No 	UPN		
UCI		ULN		
Address Including postcode				
Telephone number				
Parent/Carer details	1st Contact	2nd Contact		
Name				
Relationship to pupil				
Telephone number	
			
Address if different from pupil’s home				
Email address	

SEND Information
						
Is the pupil on your SEND register? 
	Yes/No                 
		Does the pupil have an EHCP? 		    Yes/No                 

Has the pupil had any input from an Educational Psychologist?
	Yes/No                  

		Has the pupil received any additional support in or out of class?
		    Yes/No        

	
Do parents have any concerns regarding any SEND issues? 
	Yes/No 		Please include the contact details of your SENCO

			

Main Needs
						
Does the pupil display any difficulties concerning: (Please highlight)						
Speech and Language
Dyslexia
Dyspraxia			ASD
ADHD
Other			

Medical/Health Information
						
Does the pupil have any medical issues that we need to be aware of?
	
    Yes/ No		Is the pupil currently taking any medications?

		    Yes/No                     	
If Yes please state in the attached box 			If Yes please state in the attached box 		

Safeguarding
						
Is the pupil subject to a Child Protection Plan?  				            
 Yes/No                                       		

Safeguarding status
				  
 CIOC            CP                CIN              CAF
		
Name of Social Worker 		 				
Telephone number/email address						
Details of home situation		

Have the pupil’s parents/carers been contacted and are they in agreement with this referral?		                         Yes/No 				
Does the pupil agree with the referral?
		                         Yes/No       				
Has the pupil previously attended an AP? (if so, please provide further information, including contact details) 

Risk Assessment						
Area of risk	Low	Med	High	Details	Action to minimise risk	
Verbal aggression	
					
Physical aggression	
					
Wandering off or absconding						
Offending behaviour	
					
Self-harming behaviour						
Medical issues
						
Substance/drug abuse	
					
Sexualise behaviour towards children						
Sexualise behaviour towards adults						
Allegations
						
Activities to be avoided						

						
Communication needs						

						
Comments						

						

Agencies involved – please tick				
	✔	Date of involvement	Named contact and telephone number	
CAMHS				
ELCAS				
Children Services 				
Engage				
Mental Health Service Team				
Wish Centre				
Youth Justice System				
Any additional agencies involved

Referring School						
Name of School 	 					
Name 	 					
Position 	 
					
Point of contact from referring school						
Telephone number 	 
					
Email 	 					
% Attendance 	 		Has this pupil had exclusions?		     Yes/No                  	
% Authorised Absence 	 		Number of days		 	
% Unauthorised 
Absence 	 		Number of occasions		 	
Academic						
Key Stage 2 results 
	Maths:
English:		CAT scores
			
Reading Age
			Spelling Age			
Expected GCSE Grades (if applicable)						
English Literature				Maths		
English Language				Science		
Art				GCSE PE		

Additional documentation required: 	Included – please tick 	
1. Copy of attendance record 	 	
2. Latest academic report	 	
3. Exclusion history with reasons 	 	
4. Copies of EP reports, medical reports and information from other agencies if appropriate	 	
5. Copy of EHCP and ILP’s	 	
6. Copy of TAF plans if appropriate	 	
7. Behaviour Log		

Placement Agreement	
Reason for referral (please explain in detail)	

Placement Objectives (What objectives you would like the pupil to achieve during their placement with ourselves e.g. behaviour to improve, attendance to increase, successful destination, Post 16, in Education, Training or Employment, good academic achievement in GCSE Examinations, re- engagement with their education, Improved relationships with peers, SEND needs being fully supported, mental health needs being fully supported)	
1.	
2.	
3.	
Timeline	
For all Key stages, placement reviews will be carried out every 6 weeks however, a placement may end early in the case of:
-	Persistent absence
-	The school being unable to meet the needs of a pupil
-	A serious breach or persistent breach of the school behaviour policy or rule	
Reviewing progress - how would you like to conduct the review of progress made?	
Phone call                             Email                               Zoom/Teams meeting              Face to face	
Transition details (if applicable)	

Provider
			
Referring School 
			
Signed by Headteacher (Provider) 		Date: 	
Signed by referring School including job title 		Date: 	

Boxall Assessment KS4

Pupil Name

Developmental Strands

Enter scores for Section 1 items in the appropriate column of section 1 histogram

Score each item in turn according to the Key below
4 Yes, or usually
3 At times
2 To some extent
1 Not really, or virtually never
0 Does not arise, not relevant.
                                                                                                                                                      		     Score      Column
1	Listens with interest when an adult explains something to the group	 	 
A	
2	Takes appropriate care of something s/he has made or work s/he has done
Investment of feeling in his/her achievement is implied, and self esteem	 	 
F	
3	Appreciates a joke or is amused by an incongruous statement or situation
Disregard lack of appreciation of a joke which is at his/her expense disregard amusement that is clearly inappropriate	 	 
D	
4	Is able to bring to a close an enjoyable activity when the adult, with adequate warning, makes a general request to the group (Score 2 if a personal and specific request is needed)	 	 
G	
5	Makes and accepts normal physical contact with others
e.g. in drama, dance, PE, group games.	 	 
H	
6	Makes appropriate and purposeful use of the materials/equipment/toys provided by the adult without the need for continuing direct support
Disregard repetitive activity which does not progress	 	 
A	
7	Maintains acceptable behaviour and functions adequately when the routine of the day is disturbed
e.g. unexpected visitors, supply teachers.	 	 
H	
8	Makes an appropriate verbal request to another pupil who is in his/her way or has something s/he needs	 	 
H	
9	Complies with specific verbal prohibitions on his/her personal use of equipment
Score 2 if s/he complies but often protests or sulks	 	 
G	
10	Abides by the rules of an organised group activity. Interacts, co-operates and continues to take part for the full duration of the activity
(e.g. during PE, drama, Circle Time or a group discussion)	 	 
J	
11	Accommodating to other pupils when they show friendly and constructive interest in joining his/her activity of a group	 	 
H	
12	Listens, attends and does what is required when the adult addresses a simple positive request specifically to him/her  e.g. to get out his/her work book	 	 
A	
13	Works or play alongside another pupil who is independently occupied, without interfering or causing disturbance	 	 
G	
14	Shows awareness of happenings in the natural world, is interested and curious, and genuinely seeks explanations	 	 
B	
15	Of his/her own accord returns to and completes a satisfying activity that has been interrupted 
e.g. s/he finishes a painting or carries on with a project later in the day or the following day	 	 
C	
16	Is adequately competent and self-reliant in managing his/her basic personal needs
e.g. hygiene issues, changing for PE	 	 
A	

                                                                                                   
Section 1a
Development Strands
                                                                                                                                                                            Score     Column
17	In freely developing activities involving other pupils s/he constructively adapts to their ideas and suggestions	 	        I	
18	Turns to an adult for help, reassurance or acknowledgement, in the expectation that support will be forthcoming. Disregard occasional negativism	 	F	
19	Accepts disappointments	 	J	
20	Participates in adult led group activity e.g. group discussion, group performance	 	A	
21	Shows genuine interest in another pupil relays a personal experience; pays attention and gains from experience; does not intrude; does not take over	 	B	
22	Shows genuine concern and thoughtfulness for other people; is sympathetic and offers help	 	I	
23	Recalls information of relevance to something s/he reads or hears about and makes a constructive link	 	C	
24	Makes constructive and reciprocal friendships which provide companionship
Score 3 if the friendship is with one pupil only Score 2 if no friendship lasts longer than a week Score 1 if the association is fleeting, albeit constructive and reciprocal	 	D	
25	Contributes to the course of co-operative and developing activity with two or more pupils and shows some variation in the roles s/he takes
e. g. lead role, support role, mediator.	 	E	
26	Is reasonably able to prepare for planned tasks, organise required equipment and clear away
e. g. arrives at agreed time, organises equipment, pencils, pens, books, PE kit.	 	B	
27	Communicates a simple train of thought with coherence
e.g. an oral or written description of events	 	C	
28	Responds to narrative stories with appropriate feelings; is able to identify characteristics in fictional texts	 	D	
29	Makes pertinent observations about the relationship between two other people; appropriately attributes and motives to them	 	D	
30	Engages in conversation with another pupil
Where an interchange of information, ideas or opinions is  implied	 	E	
31	Looks up and makes eye contact when an adult is nearby and addresses him/her by name	 	F	
32	Sits reasonable still without talking or causing disturbance when the adult makes a general request to a group of pupils for their attention	 	G	
33	Gives way to another pupil’s legitimate need for the equipment s/he is using by sharing it with him/her	 	H	
34	Shows curiosity and constructive interest when something out of the ordinary happens
Is secure enough to accept a change or the introduction of something new, is alert to the possibilities of the event and gains from it.	 	D	
 
Section 2 
Diagnostic Profile

Enter scores for Section 2 items in the appropriate column of section 2 histogram
Score each item in turn according to the Key below
4 Like this to a marked extent
3 Like this at times
2 Like this to some extent
1 Only slightly or occasionally like this
0 Not like this at all
(if behaviour may exist but has not been observed leave score blank)
                                                                                                                                                                           Score      Column
1	Abnormal eye contact and gaze	 	V	
2	Avoids, rejects or becomes upset when faced with a new and unfamiliar task, or a difficult or competitive situation	 	R	
3	Variable in mood; sometimes seeks and responds to affectionate contact with the adult, at other times rejects or avoids	 	W	
4	Oblivious of people and events; doesn’t relate; is out of contact and can’t be reached	 	Q	
5	Uncontrolled and unpredictable emotional outbursts or eruptions that release and relieve pent-up and endured anger or distress	 	X	
6	Inappropriate noises, remarks, or behaviours, that are appear unrelated to the current situation	 	T	
7	Erupts into temper, rage or violence when thwarted, frustrated, criticised or touched; the trigger is immediate and specific	 	Y	
8	Relates and responds to adults in an immature way	 	S	
9	Always has to be first, must be the best; demands the most attention or immediate attention	 	Z	
10	Adopts stratagems to gain and maintain close physical contact with the adult	 	U	
11	Lacks trust in the adults; intentions and is wary of what they might do; avoids contact; and readily shows fear	 	V	
12	Self-conscious and easily rebuffed, and hypersensitive to disapproval or the regard in which s/he is held by others	 	R	
13	Contrary in behaviour; sometimes helpful, co-operative and compliant, at other times stubborn, obstinate and resistive	 	W	
14	Repetitively pursues a limited task which does not progress	 	Q	
15	Spoils, destroys, or otherwise negates the achievement or success s/he has worked for and values	 	X	
16	Gives uninhibited expression to boisterous and noisy behaviour, is not influenced by normal social constraints and expectations	 	T	
17	Reacts defensively even when there is no real threat; is evasive, blames others, finds excuses or denies	 	Y	
18	Over-reacts to warmth, attention or praise and responds inappropriately	 	S	
19	Desperately craves affection, approval and reassurance, but questions the sincerity of the regard shown; seeks it repeatedly but remains insecure	 	U	

 Section 2 A
Diagnostic Profile
                                                                                                                                                                         Score          Column
20	Has difficulty waiting; will push in, grab or take without consent	        	     Z	
21	Functions and relates to others minimally, and resists or erupts when attempts are made to engage him/her further	 	     V	
22	Self-disparaging and self-demeaning e.g. “I can’t do this,” “I’m rubbish at this”)	 	     R	
23	Attention-seeking in a bid for recognition or admiration	 	     W	
24	Disparaging attitude to other pupils; is critical and contemptuous	 	     Y	
25	Listless and aimless; lacks motivation and functions only with direct and continuing support or pressure	 	     Q	
26	Sulks when disapproval is shown, or when attention is withdrawn, or when thwarted	 	     X	
27	Shows fleeting interest and has limited concentration	 	     T	
28	Remembers a real or imagined offence, bears a grudge and determinedly takes his/her revenge	 	     Y	
29	Possessive of personal objects and resists having them taken away	 	     S	
30	Sullen, resentful, and negative in general attitude and mood	 	     V	
31	Can’t tolerate even a slight imperfection in his/her work and is upset or angry if s/he can’t put it right	 	     W	
32	Feels persecuted; believes others are against; him/her, and complains of being ‘got at’ and left out	 	     X	
33	Restless and erratic; behaviour that lacks direction	 	     T	
34	Determinedly dominates or persecutes by bullying, intimidation, and the use of force	                         	     Y	
 
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