St Sebastian's Catholic Primary School - Pastoral Referral Form 
At St Sebastian’s, we are committed to promoting positive mental health and emotional wellbeing to all students.  We know that children learn best when they feel happy, safe and secure. All staff work together to ensure that children in our care achieve their best educationally, emotionally and socially. 

Our Pastoral Lead /Senior Mental Health Lead ( Niamh Fay) works in school with staff to support our children and their families who are facing challenges in their lives. Referrals to the Pastoral lead can be made by class teachers, families and the children themselves.  

The Lead is available to support children and their families with challenging circumstances that they may face either at school or at home.


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Childs Full Name *
Childs Class *
Name of Referrer (completing this form) *
Relationship to Child *
Other professionals involved (e.g. CAHMs, MHST, Alder Hey, ADHD Foundation. ASD Team)  *
Reason for Referral, please tick all that apply *
Required
Please specify if other... *
 What are you worried about? How long has the problem presented? What changes have you noticed?  
*
How severe is the situation? Rate on a scale of 1-10 where 1=mild, 5/6 = moderate and 9/10 =severe *
 What has happened in the past? Any major trauma / events in family / school / social life?  
*
Preference of contact  *
Any additional information *
Parent/ Carer Signature

I understand that details given in this referral form may need to be shared with members of the pastoral and safeguarding team.


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This form was created inside of St Sebastian's and St Cuthbert's School Federation.

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