Parent Referral Form-Pastoral Care

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If you have concerns about the well-being of your child at school and would like some support from our team, please fill out this form and a member of our Pastoral Care Team will contact you. If the matter is urgent, please contact the school and ask to speak to Kristy Robb.

Date *

YYYY

Name *

Teacher *

Name of Referrer *

Does your child identify as Indigenous? *

Yes

Does your child have a Personalised Plan? *

Yes

Please give details of any specialists your child is seeing

If there is an existing diagnosis, please provide information otherwise mark as N/A *

Detailed reason for referral *

Has this concern been discussed with your child's teacher? *

Yes

Details of conversation with the teacher if applicable *

What is the desired outcome from contact with the Pastoral Care Team? *

Thank you for your referral. A member of our Pastoral Care Team will contact you shortly.

**Pastoral Care Team Administration Section**

Allocation

Plan of Action

Closing Date

YYYY

SchoolWorx Summary Complete

Yes

Submit

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