Referral Form for Jogo Behaviour Support

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CONFIDENTIAL

REQUEST FOR CONSULTATION, ADVICE AND SUPPORT

Behaviour Support for Pupil/Student

* Pupil/Student Name: Please enter Pupil/Student's name

* DOB: Required

* Gender: Required

* School Name: Please enter the school's name

* Current School Year: Required

School Address: Required

Legal Status: Required

Ethnicity: Required

Your/Their Reference: (You can enter a reference number for the pupil/student if applicable) Required

Does the pupil/student have an education, health and care plan or any other kind of individual plan? If yes please give details: Required

SECTION 2

Nature of concern / Identified Need / Issue: Required

What actions have been taken to address concerns/issues? Required

What have been the outcomes of these actions? Required

What do you hope to achieve as a result of the involvement from Jogo Behaviour Support? Required

Involvement of other agencies

Agency: Required

Summary of Involvement: Required

Date: Required

Parent / Carer Views

Details: Required

Parent(s) / Carer(s) Signature(s):

(Parents signature can be collected from hard copy of form at first meeting. A Parent/Carer name in the signature box indicates parental permission for initial meeting)

Required

Pupil / Student's Views

Required

Parent / Carer Contact Details

Main Parent / Carer Name and Address:

Please give parent/carer contact details

E-mail Address: Check for valid email address

Contact Phone Number: Required

Parent / Carer 2 Contact Details (if different to above)

Required

Class Teacher / Form Tutor Details

Teacher / Tutor Name: Required

Email Address: Check for valid email address

Completed By

* Your Name: Required

* Designation / Position: Required

* Phone: Required

* Email: Valid email address required

Date: 21st November 2024

* = required information

Privacy Statement for Jogo Behaviour Support Services

Information Jogo Behaviour Support will hold and why

Jogo Behaviour Support collects the pupil/student's contact details so that we can provide the requested support services. Jogo Behaviour Support needs the pupil/student's name, and date of birth to ensure reports have the correct details. These details will be stored on Jogo Behaviour Support's encrypted and password protected online database and personal server. This server is backed up every evening. During the support, Jogo Behaviour Support will create notes about the pupil/student and any medical needs. Jogo Behaviour Support will create a running record of the sessions so that they can remember when meetings and sessions took place and the support offered.
Parental consent will be required.

How Jogo Behaviour Support keeps your data secure

Jogo Behaviour Support will store the pupil/student's contact details on our encrypted and password protected online database and server. Notes are stored in a Jogo Behaviour Support locked filing cabinet and will scanned onto Jogo Behaviour Support's encrypted and password protected online database and personal server, along with electronic records and reports. All electronic equipment is password protected. When Jogo Behaviour Support's practitioner is travelling with printed notes, they will ensure the documents are protected and remain in their possession at all times. The signed contract and initial referral form are stored on our encrypted and password protected online database and server.

How long Jogo Behaviour will keep it for

Jogo Behaviour Support will keep your contact details, email messages and texts for 12 months after the pupil/student's case is closed so that we or they can contact you about any reports still being written and offer a follow up review. After that, they will be deleted them from electronic devices that they are stored on except our encrypted and password protected online database and personal server. Jogo Behaviour Support will keep the pupil/student's notes, running record of support and summary report until no longer required by statute and then erase them using the most secure method available at thattime.

Who Jogo Behaviour Support will share the data with

Jogo Behaviour Support will not share the contact details with anyone without further consent. We have agreed a Circle of Confidentiality and these are the people you are happy for Jogo Behaviour Support to share reports with and to talk to about the pupil/student and the support offered. When Jogo Behaviour Support sends a report or other information, it will be sent via an encrypted and password protect email system called Egress. The only times Jogo Behaviour Support may have to share the data would be if requested to do so for lawful reasons.

Non-Consent

If the parent or legal guardian wishes to remove their consent to Jogo Behaviour Support use of the data or for the pupil/student to receive support at any point, please let Jogo Behaviour Support know by email or in writing. However, please understand that Jogo Behaviour Support would not then be able to continue to support the pupil/student.

Having access to the data

Under GDPR the data subject or their parent/legal guardian have rights as an individual which they can exercise in relation to the information Jogo Behaviour Support hold about the pupil/student. See https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/right-to-be-informed/.

Complaints

If you have any concerns about how Jogo Behaviour Support have handled the data, you can complain to the Information Commissioner's Office.

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