Name: Year:

Referred By: Shane Basham Date: 16 Nov. 18

1. If the student Is being referred for;

Highly Offensive or Threatening Language specifically directed at an individual.
Refusal to follow instructions.
Wilful Damage.
Breach of school Drugs/Alcohol policy.
Threatening or actual physical violence.
Contact HOLA or Student Services Immediately/ASAP. Otherwise proceed to step 2,
2. Expectations not met: Describe what has occurred;
Comments

3. Teacher Expectations (Tick completed before referring onwards)

Expectations taught to class.
Employ CMS (Scan, proximity, signal to start/stop, pause).
Low Key Verbal Reminder.
Square off, formal direction.
Provide choice to student. (Change Behaviour or Consequence)
Student provided with consequence. Details/Date
Completed
Re-explain expectations after completion of consequence.
Contact Parent to communicate concern and resolution – (details/date).

Student sent to buddy class.

Enter data on SIS.
Referred to HOLA
4. Hola Actions (Tick completed before referring onwards)
Buddy class, detention or alternative consequence (Details/Date).
Completed
Contract/Resolution document completed outlining expectations and future consequences.
Contact Parent to communicate concern and resolution – (details/date).

Enter data on SIS.

Refer to Student Support (student still unable to meet expectations)
5. Student Support Actions (Tick completed before referring onwards)
Manage imminent risk/investigate incident (for Stage 5 referrals only).
Implement appropriate escalated consequences (Details/Date).

Completed
Organise Case Conference with appropriate individuals to attend.
Develop IBMP with appropriate individuals and review dates.
Canvas support from 0ff-site support personnel and agencies.
Loss of Good Standing
Parent contact – mandatory for in or out of school suspension. (Details/Date).

Document on SIS
Follow up action/risk management (Attach details if necessary)