Specialist Inclusion Support Service Referral

Only schools or health care professionals can make a SISS referral.

* Is this referral being made on behalf of the Virtual School

Child's details

* Child's name

Preferred name

* Date of birth

Gender

* Address

* Is the child looked after by the local authority

* Number of children in the family

Position in the family (e.g. 2 of 3)

Are any other language spoken in the family home

Parent/carer details

Provide names and addresses, if different, for each parent or carer and indicate who has parental responsibility

* Name

* Relationship to child

* Address

* Postcode

* Home telephone

Mobile telephone

Parent/carer details (if different)

Name

Relationship to child

Address

Postcode

Home telephone

Mobile telephone

Referrer details

* Name

* Address

* Designation

* Contact telephone

Reason for Referral

* What is the primary need or difficulty

Autism

If you selected Autism, what is the reason for the referral

CLD - Communication and Learning Difficulties

If you selected CLD what is the reason for the referral

SEMH - Social, Emotional and Mental Health

If you selected SEMH what is the reason for the referral

PD - Physical Disability

If you selected PD does the person you are referring have a diagnosed condition

If Yes, what is the diagnosis

When was the condition diagnosed (DD/MM/YYYY)

Who diagnosed the condition

SLCD - Speech, Language and Communication Disorder

If you selected SLCD, what is the reason for the referral

Further information

School support

Education and Health Care Plan (EHCP)

Please include details of other services working with the CYP, referrals in place etc.

Parental consent

The referrer can complete the following questions on behalf of the parent/carer and confirm they have explained all the options and are accurately reflecting the parent/carer’s wishes. The referrer is also confirming that they have explained the purpose of the referral to SISS and obtained 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 organisations 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, school/nursery the action and support which will need to follow.

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.

* 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 704 6690 or via email at sissadminoffice@solihull.gov.uk.

* I give consent for you to record and hold my information for the purposes explained to me.

* Name of Parent/Carer

* Parental consent obtained from (Name of parent/carer)

* By (Name/Title of referrer)

Confirmation

To receive a copy of your completed referral enter your email address

Data Protection

Your information may be shared with other council services and partner organisations to ensure our records are kept accurate and to help us to identify services or benefits you may be entitled to or interested in. 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.