Skip to form
Professional Referral Form
This form is to be completed by a professional who has an understanding of the student’s educational support needs. A suitable referee includes a member of the school leadership team, Guidance Officer, Counsellor, mental health practitioner or support worker. Ideally, the form is completed by the current or most previous school to identify disengagement from schooling and supports implemented to engage the student in learning.
Referrer Details
Referrer first name
Referrer last name
Referrer email
*
Referrer phone number
School/Organisation
Position title
Student Details
TYS Student First Name
TYS Student Last Name
Student Date of Birth
Day
/
Month
/
Year
Current School
Grade applying for
*
Please Select
Grade 6
Grade 7
Grade 8
Grade 9
Is the student of Aboriginal or Torres Strait Islander decent?
Please Select
No
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
Student Gender
Please Select
Female
Male
Other
Student Pronouns
TYS Has the student been suspended?
Please Select
Yes
No
Unsure
What were the circumstances of any suspensions?
Please describe the student's current schooling situation
Adjustments and Modifications
Has the student previously had adjustments made in school?
No
Emotional regulation support
Behavioural support
Reading/Writing support
Maths support
Student NCCD Status
Has the student been identified in the Nationally Consistent Collection of Data (NCCD) for Students with Disability?
Please Select
Yes
No
Unsure
Student NCCD Category
Please Select
Cognitive
Social/Emotional
Sensory
Physical
Student NCCD Level of Adjustment
Please Select
QDTP
Supplementary
Substantial
Extensive
Has the student been professionally diagnosed with any of the following
Hearing Impairment
Speech Language Impairment
ASD (Autism, Asperger's, PDD-NOS)
Borderline Intellectual Difficulties
Oppositional Defiance Disorder
Physical Impairment
Intellectual Disability
ADD/ADHD
Speech/Language Difficulties
Conduct Disorder
Visual Impairments
Social/Emotional Disorder
Dyslexia
Dyspraxia
Sensory Processing
Please provide information about the student’s disengagement and what adjustments could assist the student to engage in learning?
Is there any other health. medical or background information it would be helpful for us to know about the student?
Is there any other information that you consider would be helpful in the nurture and education of this student?
Please attach any relevant assessments, reports, or additional relevant information regarding the student's needs, e.g., individual learning plan, behaviour support plan, and safety plan.
Supporting Information
I confirm the answers and information provided in this questionnaire are true and correct to the best of my knowledge and belief and understand this information may be used by The Younity School and its agents in the student enrolment process and may be accessed by students and their representatives.
Yes I agree
*
Submit