COBURG TEACHING UNIT

P.O. Box 260, Coburg, 3058

(189 Urquhart, Coburg)
Tel: 9354 2600 Fax: 9350 1716
http://www.coburgteachingunit.vic.edu.au

STUDENT REFERRAL 2016

STUDENTS PERSONAL DETAILS
STUDENT'S NAME: ............................................................D.O.B:.....................YEAR LEVEL: ...........
HOME ADDRESS: .................................................................................POST CODE:..........................
MOTHERS NAME:..................................................PHONE:..........................EMAIL:..............
FATHERS NAME: ........................................................ PHONE: .......................... EMAIL.................
PREVIOUS SCHOOLS: ..........................................................................................................................
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SCHOOL DETAILS
REFERRING SCHOOL: ......................................................................................................................
ADDRESS: ..............................................................................POST CODE...................................
PHONE: ...........................................FAX:................................EMAIL:............................................
STUDENT WELFARE COORDINATOR: ...............................................................................................
YEAR LEVEL/SUB-SCHOOL CO-ORDINATOR: ...............................................................................
CONTACT PERSON WITHIN THE SCHOOL: ...............................................................................
REFERRAL DATE: ......../........../2016.

CURRENT SUBJECT TEACHERS:

NAME:

SUBJECT:

1. .......................................................................

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2. .......................................................................

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3. .......................................................................

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4. .......................................................................

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5. .......................................................................

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6. .......................................................................

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7. .......................................................................

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SECTION 1

TEACHING UNIT PROGRAM

The aim of the Coburg Teaching Unit is to provide an intensive educational and social skills program for students at risk of disengaging from
school. Our primary aim is to work with the school to reintegrate the student into the classroom better equipped to participate successfully. The
program normally runs for approximately 10 weeks, during which time the student will spend 4 days per week at the Unit and one day a week at
school (Wednesdays) attending their usual classes. The student will have negotiated goals for this day and will be visited by his/her contact
teacher from the Unit.

TO BE COMPLETED BY THE REFERRING TEACHER

1. Reasons for referral.
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2. In what ways is it anticipated that a placement at the Unit will assist the student?
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3. Have DEECD Regional staff been involved with the student?
No

YesProvide details: name and date:..

.
4. Have any suspension or inquiry procedures taken place? Please give details.
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5. Attach or outline the Staged Response the school has taken to help the student.
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Report attached

* Please obtain approval to release copies of reports

6. Indicate DEECD Allied Health officers involvement including assessments with the student?
Psychologist

Speech Pathologist

Social Worker

other e.g nurse

Report attached*

7. Indicate referral or assessed by other agencies

DHS

RCH

MHS

Medical Specialist

other

Report attached*

8. Has the student had a vision impairment test?

No

YesPlease provide details:...............................................................................

9. Has the student had a hearing impairment test?

No

YesPlease provide details:...............................................................................

10. Is the student receiving support from the Disability and Impairment program?
No

YesPlease provide D&I funding level and criteria:...............................................................

11. Does the student have a Behaviour Support Plan?

No

Yes

Plan attached

12. Does the student have an Individual Learning Plan?

No

Yes

Plan attached

13. Does the student have a Mental Health Care Plan?

No

Yes

14. Does the student have a Student Support Group?

No

YesPlease provide details of composition and frequency:..................................................

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15. Family background (current living arrangements, siblings, custodial agreements).

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16. List the student's strengths and personal resources.
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17. Has the students attendance been regular? Please give details.
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18. Medical history/general health (include any medication the student is taking)
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19. Is there any additional information, which may be relevant?
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20. Please attach copies of the students most recent subject and NAPLAN reports.

Referring Teachers Name: .................................................................................................................................

Position: .......................................................... Signature: ....................................................................................
Principals Signature: ....................................................................... Date: ..........................................................
Office use onlyRef.Date:...............

Completion of this referral form does not guarantee placement.

* Please note: The referring school will be invoiced $350.00 on confirmation of placement.

SECTION 2
Student

(TO BE COMPLETED BY SUBJECT TEACHERS)

Teacher

Subject

Academic

AusVELS Level

Yes/
No

Comment if Applicable

1. Completing work at expected level

2. Completing modified work requirements
3. Completing set tasks satisfactorily
4. Experiencing success

5. Requesting assistance when required

6. Well organised

Social Skills

Rarely
1

Always
2

N/A

1. Mixes effectively with other students

2. In class can work appropriately in small group
3. Can play games fairly, according to rules
4. Responds appropriately to winning and losing

5. Can negotiate to fulfil own needs

6. Is aware of consequences of own behaviour
7. Has appropriate anger management skills

Behaviour

Rarely
1

Always
2

N/A

1. Behaviour is appropriate in the classroom

2. Behaviour is appropriate in the schoolyard
3. Participates effectively in class
4. Contributes to a positive classroom environment
5. Speaks appropriately to teachers and other students
in class
List the students strengths and resources ......................................................................................................................................
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General Comments ..