V. 10 08 21	
Student Passport:
Referral for student support through Southway	

Name:		Year:		
				
School:		
				
Contract Meeting Date:		On Roll Date:		

	

Southway Admin Use Only				
	Checked & Added to Referral Data	Claire Boardman	Key Worker:		
CTF Provided	
Yes / No 	
CTF Downloaded	
Yes / No 	
CTF Imported into SIMS	
Yes / No 	

	

	

S/W Placements	
Yes / No 	
Invoicing	
Yes / No 	
Assessment Tracking	
Yes / No 	

	

	

Examination Entries	
Yes / No 	
Student Sheets	
Yes / No 	
Student School List	
Yes / No 	

	

	

CPOMS	
Yes / No 	
EduKey	
Yes / No 	
Classcharts (download) 	
Yes / No 	

	

	

GL Assessments	
Yes / No 	
EdLounge	
Yes / No 	
Risk Assessment received	
Yes / No 	

Important Information:
To save any delays in support for the student/s and your school, we will require all the passport completed and an up to date copy of the students risk assessment/s. Failure to provide adequate information thoughout, will result in delays, and a returned passport for further attention.	

School Contact Details:
School:	

	

	

School Contact:	
	
Job Title:	

	

	

Tel No (DDI):	
	
Ext:	

	

	

Email Address:	

	

Referral Status for Dual Registration:
South AIP	
	
C/W SEMH Panel 	
	
Private Referral	
	
Out of Area	
	
OOA Location	

	

PX	
	
Other AIP Area	
	
which Area AIP	

	

Registration Information: (Included in CTF - Yes   No )
Year Group:	
	
Admission Date:	

	

	

UPN:	
	
Unique Learner No.	

	

	

UCI:	
	
Exam Number:	

	

Student Details: (Included in CTF - Yes   No ) 
Legal Forename:	
	
Photograph:	

	

	

Middle Name(s):	

	

	

Legal Surname:	

	

	

Preferred Surname:	

	

	

Preferred Forename:	

	

	

Date of Birth:	

	

	

Gender:	

	

Current Address & Family Details: (Included in CTF - Yes   No ) 
House No:	
	
Street:	

	

	

Town:	
	
City:	

	

	

Postcode:	
	
Address Type:	
	
(Home, Family, Care, Other)	

(Included in CTF - Yes   No ) 
Primary Contact:	

	

Forename:	
	
Surname:	

	

	

Relationship:	
	
(Mother, Farther, Grandparent etc)	

	

Telephone No. H:	
	
Main/Primary Number:	

	

TelephoneNo. M:	
	
Main/Primary Number:	

	

Telephone No. W:	
	
Main/Primary Number:	

	

Email Address:	

	

2nd Contact:	

	

Forename:	
	
Surname:	

	

	

Relationship:	
	
(Mother, Farther, Grandparent etc)	

	

Telephone No. H:	
	
Main/Primary Number:	

	

TelephoneNo. M:	
	
Main/Primary Number:	

	

Telephone No. W:	
	
Main/Primary Number:	

	

Email Address:	

 	

3rd Contact:	

	

Forename:	
	
Surname:	

	

	

Relationship:	
	
(Mother, Farther, Grandparent etc)	

	

Telephone No. H:	
	
Main/Primary Number:	

	

TelephoneNo. M:	
	
Main/Primary Number:	

	

Telephone No. W:	
	
Main/Primary Number:	

	

Email Address:	

 	

Known Medical Conditions: (Included in CTF - Yes   No ) 
Name of Doctor surgery: 

Any know medical conditions:	
Yes	

No	

	

If yes, further details (including any medication that will be brought into school):	

	

	

Ethnicity/Cultural: (Included in CTF - Yes   No )
Ethnicity:	

Banladeshi:	
	
Indian:	
	
Kashmiri Pakistani:	
	
Other Pakistani:	
	
Other Asian:	

Black Caribbean:	
	
African:	
	
Any other Black background:	
	
Chinese:	

White/Black African:	
	
Any other Mixed Background:	
	
White/Asian:	

White/Black Caribbean:	
	
Info Not Obtained:	
	
Any Other Ethnic Group:	

British:	
	
Irish:	
	
Any Other White Background:	

	

Traveller – Irish Heritage:	
	
Gypsy/Roma:	

	

	

School History: (Included in CTF - Yes   No )
Current School:	
	
Start Date:	

	

	

Attendance at the end of each academic year on roll (%)	

	

Yr.7	
	
Yr.8	
	
Yr.9	
	
Yr.10	
	
Yr.11	

	

	

Current % of current year	

	

	

Exclusions in Last Academic Year	
No of Exclusions:	
	
Total Days:	

	

	

Exclusions in Current Academic Year	
No of Exclusions:	
	
Total Days:	

	

	

Please provide details of any previous schools/provisions:	

	

	

School/Provision 1:	

	

Start Date: (If known)	
	
Leaving Date: (If known)	

	

	

School/Provision 2:	

	

Start Date: (If known)	
	
Leaving Date: (If known)	

	

	

School/Provision 3:	

	

Start Date: (If known)	
	
Leaving Date: (If known)	

	

	

Please provide details of last known primary school:	

	

	

School Name:	

	

Start Date: (If known)	
	
Leaving Date: (If known)	

	

Information Requested – Please send the followng at the time of your referral:
•	A SIMS Attendanace Certificate for current and previous year.
•	A copy of the Last Academic Report.
•	A Risk Assessment if relevant

SEND Information: (Included in CTF - Yes   No ) 
Current SEND status e.g. K	

	

	

	

Is the child currently undergoing or have they ever undergone an EHC Plan?	
Yes	

No	

	

	

	

If Yes, please provide details of the plan and SENCO details	

	

	

	

Does the child have a Statement of SEND/FFI support?	
Yes	

No	

	

	

If Yes, how many units of funding are attached?	

	

Risk Assessment:

Does the student have a current Risk Assessment?	
Yes	

No	

	

	

Do you feel the student needs a Risk Assessment?	
Yes	

No	

Context of why one is not in place?                                                                                                               

If yes, please attach a copy, if No – please complete the Risk Assessment which was sent out with this passport.	

	

	

	
	
Copy Attached	
	
Completed Attached	

	

	

Does the student have a current Individual Learning Plan/Individual Behaviour Plan (ILP/IBP)	
Yes	

No	

	

	

If yes, please attach a copy.	
Attached	

	

Does the student have a current Positive Handling Plan (PHP)?	
Yes	

No	

	

	

If yes, please attach a copy.	
Attached	

	

School SEND Co must complete the Provision Mapping below.

Cognition & Learning	
Yr 7	
Yr 8	
Yr 9	
Yr 10	
Yr 11	

Literacy	

Toe by Toe	

	

Active Literacy Kit	

	

Dockside	

	

Units of Sound	

	

Lexia	

	

Accelerated Reader	

	

Word Blaze	

	

Form Time Reading	

	

After School Reading Programme	

	

Hands on Literacy	

	

GWR Comprehension	

	

Hodder Reading	

	

Stride Ahead	

	

Form Time Reading	

	

Pinsent Masons Reading Project	

	

Numeracy	

MDC Maths Intervention	

	

Form Time Maths	

	

Pinsent Masons Maths Mentoring	

	

Cognitive Ability Testing	

Coloured overlay	

	

Special Access Arrangements	

	

Dyslexia Screening	

	

Processing Speed Assessment	

	

Outside Agency	

Complex Needs	

	

STARS	

	

SALT	

	

Educational Psychologist	

	

LSU	

	

Other	

	

	
SEMH	
Yr 7	
Yr 8	
Yr 9	
Yr 10	
Yr 11	

School Intervention	

Noise Academy	

	

Art Therapy	

	

Find your Talent	

	

Shine	

	

Vulnerability Group	

	

Time out Pass	

	

Keyworker	

	

LSU/Referral	

	

Transition Group	

	

Behaviour Support	

IBP	

	

Report Black/Blue/Red	

	

Assertive Mentoring	

	

Peer Mentoring	

	

HOY/DOY 1:1 Support	

	

Outside Agency	

Cluster Referral: Early Therapeutic Worker	

	

Cluster Referral: Family Support	

	

CAMHS Referral	

	

Education Psychologist	

	

External Provision	

Footsteps	

	

Southway	

	

Hunslet Boys Club	

	

Elland Academy	

	

Stephen Longfellow	

	

Springwell	

	

Skills 4U	

	

West 14	

	

Other	

	

	

Communication & Interaction	
Yr 7	
Yr 8	
Yr 9	
Yr 10	
Yr 11	

SALT	

Social Skills Group	

	

Lego Therapy	

	

Language support	

	

SLT support	

	

SLT Monitoring	

	

SLT Intervention	

	

SLT Therapy Block	

	

EAL	

EAL in Class support	

	

EAL 1:1 Withdrawal	

	

EAL Small group Withdrawal	

	

Behaviour Support	

Peer Mentoring	

	

HOY Support	

	

DOY Support	

	

Keyworker Support	

	

Outside Agencies	

STARS Involvement	

	

SALT Referral	

	

Cluster referral	

	

School Interventions	

Travel training	

	

Find Your Talent	

	

Transition Group	

	

Access to Quiet Space	

	

LSU Referral	

	

Other	

	

	
Sensory & Physical	
Yr 7	
Yr 8	
Yr 9	
Yr 10	
Yr 11	

Outside	

DAHIT	

	

Physiotherapy	

	

Occupational Therapy	

	

School Nurse	

1:1 Emotional Support	

	

Regular Medical Support	

	

Medical Care Plan	

	

Fine Motor Skills	

Special access Arrangements	

	

Handwriting Support	

	

Laptop	

	

Other	

	

Evidence Provided:	
Yes / No 	

	

Details:	

	

Pupil Profile 

Please complete the following as this will form part of an initial profile which will be shared with Southway staff. Please provide observations detailing observations/ strategies that work to support the child and strategies that do not work. 
This will be reviewed by one of the Southway SENDCo’s in 6 weeks’ time.
 
Behavior 	Attitude to Learning 	
		
Attitude to Peers  	Attitude to Staff 	
		
Areas of Strength  	Areas of concern 	
		
Communication and Interaction 	EHCP / Reintegration Plan 	

Multi Agency Information: 
Is the student entitled to Free School Meals?	
Yes	

No	

	

	

	

Is the child subject to a EHP? (Early Help Plan)	
Yes	

No	

	

	

	

If yes, please attach a copy of the plan.	

	

	

	

Is the student entitled to Pupil Premium/Pupil Premium Plus?	
Yes	

No	

	

	

	

Is the pupil “looked after” by the Local Authority? 	
Yes	

No	

	

	

If yes, what is the pupil’s current legal status?	
Accommodated?	
Yes	

No	

	

Care Order?	
Yes	

No	

	

Start Date	

	

Is the pupil “looked after” by another family member e.g. in a kinship relationship? 	
Yes	

No	

	

	

	

If yes, please give details	

	

Is the child known to Social Services/or has been known to social services in the past 12 months?	
Yes	

No	

	

	

	

If yes, please give details	

	

	

	

Is the child subject to:	
Child In Need Plan	
Yes	

No	

	

	

	

	
Child Protection Plan	
Yes	

No	

	

	

	

Previous Child Protection Plan (last 2 years)	
Yes	

No	

	

Information included wthin the provided CTF - Yes   No 

Current Social Worker Details	

	

	

	

Name	
	
Office Telephone	

	

	

Email	
	
Mobile Telephone	

	

	

Is the pupil caring for another family member?	
Yes	

No	

	

If yes, please provide further information	

	

Are there known Child Protection/Safeguarding issues?	
Yes	

No	

	

	

	

If yes, please provide the school’s current CP Contact/s	

	

	

Name	
	
Office Telephone	

	

Email	
	
Mobile Telephone	

	

Known Risks/Concerns.
CSE	
	
CCE	
	
County Lines	

	

	

Physical Abuse	
	
Sexual Abuse	
	
Emotional Abuse	

	

	

Neglect	
	
Mental ill Health	
	
Suicidal intent	

	

	

Self-Harm	
	
Forced Marriage	
	
Risk to others	

	

	

Prevent	
	
CSE	
	
Faith Abuse	

	

	

Financial Abuse	
	
Domestic Violence	
	
Female Genital Mutilation	

	

	

Fabricated/Induced Illness 	
	
Harmful Sexual Behaviour	
	
Institutional Abuse	

	

	

Missing from home	
	
Sexting	
	
Trafficking 	

	

	

Missing in education 	
	
Substance abuse	

	

	

	

Child Looked After	
	
Peer on Peer Abuse	
	
Sexual Harrasment 	

	

	

Weapons	
	
Drug/Substance Abuse	
	
Periods of Absconding	

	

	

Gangs and Youth Violence	
	
Anti Social Behaviour/s	
	
Domestic Violence (Child or Parent/Carer)	

	

	

Self Harming	
	
Traumatic Event/s	
	
Eating Disorder	

	

	

Bullying (victim/perpetrator)	
	
School Refuser/Social isolation	
	
Mental Health Concerns (Low mood, Low self esteem, suicidal thoughts/attempts)	

	

	

EHE	
	
Smoking cigarettes	
	
Would consider a referral to help quit Offered – Accept?	

	

	

Other	

	

Involvement of Other Agencies with Student and Family: - Please indicate if any of the following agencies are, or have been involved with the student/family
Cluster/ HUB Support	
	
Sad Events Team	
	
Forward Leeds (Drugs & Alcohol)	

	

	

Youth Offending Services	
	
MACE	
	
Child and Adult Mental Health Service (CAMHS)	

	

	

TAMHS	
	
MindMate (Front Door)	
	
Multi Systemic Therapy (MST)	

	

	

Sign Post	
	
Get Away Girls	
	
Blast	

	

	

St. Giles Trust	
	
Barca Leeds	
	
Shine	

	

	

Other:	

	

If you have ticked any of the above, please complete the following for each area. A separate sheet / file can be emailed on request if needed. (Details should be about the main person responible for working with the family / student.)

Agency Name	

	

	

Contact Name	

	

Telephone	
	
Direct Line or extension	

	

Email Address	

	

Start Date	
	
End /Review Date	

	

	

Outcome/Impact of involement of agency	

	

Agency Name	

	

	

Contact Name	

	

Telephone	
	
Direct Line or extension	

	

	

Email Address	

	

Start Date	
	
End /Review Date	

	

	

Outcome/Impact of involement of agency	

	

Agency Name	

	

	

Contact Name	

	

Telephone	
	
Direct Line or extension	

	

	

Email Address	

	

	

Start Date	
	
End /Review Date	

	

	

Outcome/Impact of involement of agency	

	

NB Please copy additional copies of this page if needed

End of Passport – the following section is to be completed by Southway staff at the contract meeting
Contract Meeting at Southway
Name of Student:		Date of Meeting:		
DOB/Year Group:		Last Known School:		
On roll date:		Group 		
Free School Meals	Yes   No 	Smokes cigarettes	Yes   No 	
				
Those Present At The Meeting:	

Details of Agreed Timetable and Assessments: 	
Progression		New Way (Progression)		
Intervention		P/T - Info		
Assessments day 1 – Date_________________________________________________  Time _______________________

Assessments day 2 – Date_________________________________________________  Time _______________________

Assessments day 3 – Date_________________________________________________  Time _______________________

Key Issues/Concerns:	
Defiance                                        Fighting                 Knife crime     General notes:
Verbally Abusive                          Known to Police                                    
Absconding                                   Anger issues
Assaulted staff/students          Refusal 	

Transport Arrangements: (Car/Bus/Walk/Cycle? If transported, by who?)	

Review Schedule: First day arrangements for MAT worker	
All reviews are termly and take place in the last week – Parent/Carer/School + Student to attend
	
Pickup from home/time 		Taxi bringing in/time		Getting dropped off/time		Other		

	

	
	
Key Contacts:(Relatives; School; Southway Keyworker)	
D Millar		C Bradney		L Jones-Cohen		K Lockwood		
	
Advised Adrian of details in preparation for Baseline Assessments Yes  - No 	
Parent/ carer consent
Please delete any statements and initial where a parent/ carer has not given permission
Emergency Transport:
In the event that my child needs to be transported home, I consent to a designated member of staff transporting my child home. The member of staff will have been granted approval by a member of the senior leadership team and they will be accompanied by a second member of staff. 
Publicity material:
As part of the Southway policy to showcase and share the learning experiences of its students, photographs/video footage may be used as evidence of your child’s work for display/publicity purposes. I grant permission for photograph/video footage of my child to be taken and or to be used as part of the positive publicity for Southway.
Acceptable IT usage statement:
The computer system is owned by the school and is made available to students, to further their education and to staff, to enhance their professional activities including teaching, research, administration and management.  The school’s acceptable internet use guidelines have been drawn up to protect all parties – the students, the staff and the school.

The school reserves the right to examine or delete any files that may be held on its computer system or to monitor any Internet sites visited.
•	Access must only be made via the authorised account and password. Which must not be made available to any other person.
•	All Internet use should be appropriate to student’s education.
•	Activity that threatens the integrity of the school ICT systems, or that attacks or corrupts other systems is forbidden.
•	Sites and materials accessed must be appropriate to work in school.  Users will recognise materials that are inappropriate and should expect to have their access removed.
•	Users are responsible for e-mails they send and for contacts made that may result in e-mail being received.
•	The same professional levels of language and content should be applied as for letters or other media, particularly as e-mail is often forwarded.
•	Posting anonymous messages and forwarding chain letters is forbidden.
•	Copyright of materials and intellectual property rights must be respected.
•	Legitimate private interests may be followed, providing school use is not compromised.
•	Use for personal financial gain, gambling, political purposes or advertising is forbidden.
Students must only use their own username and password.

*I understand and agree to support the key statements outlined in this document.

Signed:		Parent/ carer		Date:		

Print:		Parent/ carer				

*I agree to follow the rules for responsible internet use as set out in this document.
*Smoking statement/expectations

Signed/Print:		Student		Date:		

South Leeds Youth Hub, Middleton Road, Belle Isle, Leeds. LS10 3JA
T: 0113 336 7772 (Reception) ¦ E: info@southway.org.uk ¦ W: www.southway.org.uk