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Parent Referral Form-Pastoral Care
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Date
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Name
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Teacher
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Name of Referrer
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Does your child identify as Indigenous?
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Does your child have a Personalised Plan?
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Please give details of any specialists your child is seeing
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If there is an existing diagnosis, please provide information otherwise mark as N/A
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Detailed reason for referral
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Has this concern been discussed with your child's teacher?
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Details of conversation with the teacher if applicable
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What is the desired outcome from contact with the Pastoral Care Team?
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Thank you for your referral. A member of our Pastoral Care Team will contact you shortly.
Allocation
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Plan of Action
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Closing Date
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SchoolWorx Summary Complete
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