53
2022 School Referral Form
Evidence of the implementation of a Staged Response
and the student’s inability to attend a mainstream school
Stage 1 – Early identication and intervention
When did you last see
this student?
How regularly has the student
been attending classes?
What are the main factors
aecting the student's
attendance and engagement
with learning?
Stage 2 – Intervention strategies
How has the student’s learning
program been modied?
Has a Student Support Group
(SSG) been established?
Provide details and attach
most recent meeting records
and plans.
Has a consultation/referral
occurred with the DET
Health, Wellbeing & Inclusion
workforce or equivalent
Catholic/Independent system?
Have agency or community
service referrals been made?
Provide details (including
key names, contact details,
outcome of referrals and
time frames).
School Transition information
What steps are planned to
support the student to return
to your school or another
appropriate pathway?
What time frame do you
believe will be required to
enable this?
Please attach the following
documents to this referral
(please tick).
By mid-2022
The student’s most recent school report
Career Action Plan (if available)
NAPLAN report (if available)
SSG minutes
Individual Learning Plan (if relevant)
PSD Assessment/approval reports
By the end of 2022 or beyond