PROFESSIONAL REFERRAL FORM

This form is to be completed by a professional referee who understands the student’s educational support needs. A suitable professional may include a Teacher, Principal, Guidance Officer, Psychologist, General Practitioner, Medical Specialist, Social Worker, Therapist, etc.

When complete, this will be added to our waiting pool. Professional Referrals are considered by a panel as new enrolment positions become available. The team will make contact if your young person has been shortlisted. Unfortunately we can not accommodate for site visits, however please check our website for the next planned Carbrook Centre Open Day.

Student's Legal First Name *

Student's Legal Last Name *

Student's Residential Suburb *

Suburb *

Postcode *

Gender *

MaleFemaleOther

Date of Birth *

Parent /Guardian Name/s

Parent/Guardian Mobile Number *

Parent/Guardian Email Address *

What is this student's living arrangements?

Lives with biological parent/sLives with other legal guardianLives in kinship care (under Child Safety)Lives in foster care (under Child Safety)Lives in residential care (under Child Safety)Other

The criterion for Special Assistance Schools in Queensland requires a student to have disengaged or be at serious risk of disengagement from mainstream schooling. Factors may include behavior, social/emotional factors or the impact of a disability.

Does the student meet this criterion? *

YesNoUnsure

Education Details

Current School

Current Grade (this year)

Previous School/s

Grade/s

Please describe the students current schooling situation *(e.g., Suspensions, expelled, not wanting to attend, truancy, bullying, struggling at school, etc.)

Diagnoses and support needs *(e.g., complex trauma,social, academic, emotional, personal, behavioral, physical limitations)

Does the student receive NCCD Student with Disability Supports at School? (please check the level of support with the current or previous school) *

Yes, extensive supportsYes, substantial supportsYes, other supportsNo, they do not currently receive NCCD supports

What are the student's strengths, and what strategies have been used to support the student? *

What is the student's care/ living arrangements? *

How will animal assisted learning (in particular with horses or dogs) benefit the student?

Referring Person's Details

Referee Name *

Referee Organisation *

Referee Position *

Referee Relationship to Student *

How long have you worked with the student? *

Referee Email *

Referee Contact Numer *

Referee Signature *

Draw signature|Type signatureClear

Referral Date *

Confirm *

Important Information for Referrers

Please submit only the information requested in this referral form. If the student is shortlisted, we may request additional supporting documents or reports at a later stage.

You will be contacted periodically to confirm whether the student wishes to remain on the waitlist. We will send you an email and ask for a reply to confirm the student's ongoing interest.

All information collected will be handled in accordance with our Privacy Policy, available at:

Policy + Reports | Carbrook Centre

Save and Complete Later