Referral Form

Please use this form to refer a pupil to the CENMAC service. Please note that all fields are required with the exception of ‘additional comments’. If you have any problems please get in touch or email: gill@cenmac.com

Part 1: Ethnic Monitoring

We are now obliged to record the ethnic background of pupils supported by CENMAC and the following information must be completed before we can process the application.

This information should already have been given to school by the parent or child and be held on your records.

This page will be detached from the remainder of the form before being passed to the LA to seek their agreement to funding.

Part 2: Request for advice on communication difficulties

A request has been made to CENMAC to carry out an assessment on the following pupil. This is a general form – please fill in as many details as possible. It will help us with our assessment.

The pupil’s parent(s)/carer(s) must be informed of this referral and that an assessment may take place; all involved professionals should be made aware of this referral.When returning this form please include the following:

– A copy of the pupil’s Individual Education Programme (IEP)
– A copy of the Occupational Therapist’s and/or Speech & Language Therapist’s report if available
– A copy of any Hearing or Visual impairment reports if appropriate
– An example of how the pupil currently records text (handwriting/drawing) indicating whether from copy or free writing and approximate time taken

Please note This form should be completed as fully as possible as it forms part of the request to the LA for funding for the assessment.

This application form is by no means conclusive. It is designed to give us a general picture of the pupil you have referred to CENMAC.

Want to make the process run smoothly? Read on!

  • Permission must be sought from the pupil’s home LA for funding before CENMAC can assess a pupil so think of this as a “grant” application – give as much information as you can.  It will help the LA make a decision and CENMAC to arrive at the assessment well informed.
  • Your completed form is sent to the LA as part of the request for funding so what you say is important.
  • Please explain the difficulties the pupil is having and let us know what has already been tried.
  • Don’t state that a specific piece of equipment is required!  If you offer the solution the LA is unlikely to fund a request for CENMAC’s support and advice.  Remember CENMAC is an advice and support service (NOT just a loan library!).
  • Complete the form as fully as possible.  It is NOT acceptable to answer “N/A” or leave blank the question on page 2 regarding physical difficulties.
  • Make sure that the supporting information requested (handwriting/drawing sample, IEP, OT, SALT, VI, or HI reports as applicable) are included with the form.  If any of the above are inappropriate please say so on the form.
CENMAC