SfCE Dyslexia Screening Referral Form

School & Referrer Details

Name of School *

Name of person filling the form *Email address *

Role *

Head of School Deputy Head HoD Inclusion School-based Inclusion Coordinator

Name of HoD Inclusion / School-based Inclusion Coordinator *

Student Details

Name and surname of student *ID Card No. *Date of birth *Nationality *Class *

Gender *

Male Female Other

Does the student have a statement of support? *

Yes No

Does the student benefit from any other services? *

Yes No

Parent / Guardian 1

Name and surname *ID number *Contact No. *Email address *

Parent / Guardian 2

Name and surname *ID number *Contact No. *Email address *

Referral Information

Please submit the following information in liaison with the HoD Inclusion / School-Based Inclusion Coordinator.

Reason for referral * What strategies / approaches have already been used at school? * Describe briefly any behaviour of concern *

Issues / Difficulties Present in the Six Months Prior to Referral

Cognitive functioning and learning: grade each item from 1 (lowest severity) to 5 (highest severity).

Issue / difficulty *	Level of severity 1–5
Difficulty with grasping age-appropriate curriculum	12345
Literacy difficulties	12345
Numeracy difficulties	12345
Difficulty with retaining learnt information	12345
Difficulty sustaining attention	12345
Difficulty with spelling	12345
Difficulty with writing tasks	12345

Academic Performance & School Actions

Describe briefly the student’s academic performance. Does the student struggle to cope with mainstream curriculum? * Additional information on actions taken by the school *Attach an additional sheet in the PDF if necessary.

Documents Submitted *

Documents must be uploaded as ONE PDF. Tick all documents included in the PDF. Include a handwritten paragraph when spelling is the reason for referral.

Recent Psychological report (if any) Recent Occupational Therapy (OT) assessment / report (if any) Hand-written paragraph by student (if spelling is the reason for referral) Parents’ Statement of Consent

Upload ONE PDF *Only one PDF file should be submitted.

No PDF selected yet.

Privacy Statement & Consent

In valuing the privacy of personal data, the Secretariat for Catholic Education will only use the data collected from this form for the purpose of processing your application. Personal data will be stored, handled and processed in a respectful and lawful way in accordance with the General Decree on the Protection of Data (GDPD) of 2018 (accessible at GDPD 2018) emerging from the General Data Protection Regulation (EU) 2016/679. You have the right to opt out of consent and ask that collected data be deleted by sending an email to [email protected].

By providing information, I hereby consent to the personal data contained in this form to be processed in accordance with the Privacy Statement detailed above.

I understand and agree with the Privacy Statement above.

Declaration *

I confirm that, irrespective of who completes this referral, both the Head of School and the HoD Inclusion/School-Based Inclusion Coordinator are aware of and endorse this referral.

Electronic Signature *

Please sign in the box below. The electronic signature is mandatory.