Learning Support Referral Form

After consulting the Learning Support process in the Staff Handbook, please complete this form to refer in students with whom you have academic concerns

Date(Required)

Student Name(Required)

Student Year Level(Required)

Senior Students - House Dean(Required)

Referring Teacher Name(Required)

Referring Teacher Email(Required)

Subject Taught(Required)

I have consulted the referral process in the 2023 Staff Handbook(Required)

Yes

My concerns are related to the student's academic ability/performance(Required)

Yes

Does the student have a Learning Support Individual Plan (LSIP)?(Required)

Yes

Have you made a note in SENTRAL regarding the academic concerns? (Wellbeing – Student Record – Student Interview)(Required)

Yes

General concerns/ observations; please tick all that apply/ add information in 'Other'(Required)

problems retaining and recalling information

difficulties in completing a task within the time given for the majority of class

problems reading text or instructions

difficulty coping with change

persistent social difficulties with knowing what is and what isn't appropriate behaviour

hyperactivity and impulsivity

none of the above

other

General concerns/observations - other notes

Reading difficulties - select those that you have tried(Required)

use sans serif font-types, reduce “clutter” on page, enlarge text to at least size 14 font

supply copies of notes rather than requiring notes to be copied down from the board

use pictures/diagrams/graphics to support written material

explicitly teach the reading of graphs/tables/timelines etc

read passages and questions aloud, giving brief verbal summary, highlighting the main points

use peer readers

use assistive technology such as a screen reader or text-to-speech function

offer extra time to read

none of the above

Writing difficulties - select those that you have tried(Required)

explicitly teach paragraph structure and give exemplar of completed product

model how to use graphic organisers, mind maps and scaffolds to create responses

supply copies of notes rather than requiring notes to be copied down from the board

assign a smaller workload; request dot points/topic sentences instead of a paragraph

scribe for student or enlist a peer scribe

use assistive technology such as a speech-to-text tool if the classroom setting allows

provide explicit writing supports including scaffolds/ graphic organisers/ sentence starters/ word lists.

offer extra time for written tasks to be completed

none of the above

Please add further details or observations below or any information you feel will help us investigate your concerns for the student

Please submit your responses by clicking on the Submit button below. Your responses will be sent to the Academic Head of Learning Support. A copy of this form will be sent to you via email. Thank you for your referral.