Referral Form

Before Making a Referral

Please ensure you are using a recent version of Google Chrome or Mozilla Firefox before starting your referral as some versions of Internet Explorer are known to cause issues.

To ensure each young person has an equal opportunity of getting a place with iScoil, it is important that each referral application has as much detail as possible.

All information submitted is done so by encrypted means.

You will have the opportunity to include any relevant supporting documentation after submitting this form.

You will receive an email acknowledgement upon our receipt.

For more information please visit our Privacy Policy or call iScoil on 01 4537570 if you require any assistance.

Young Person Information

    • Date of Birth (in the format dd/mm/yyyy):
    • Ethnicity:
    • Language:
    • Which blended learning centre?
    • (Please use "Other" if not listed and provide the centre name in the space provided)
    • Blended learning centre name if not listed above:
    • Please provide additional details below:
    • Has the young person been referred to iScoil before?
    • (NOTE: If yes, you will only need to update any new information or change in circumstance since the last referral was submitted)
  • Please provide any new information or change in circumstances since the last referral was submitted below:

Parent/Guardian Details

  • Name of Parent/Guardian:
  • Relationship to Young Person:
  • Parent/Guardian Email:
  • Parent/Guardian Address:

School History

  • School Name and Address:
  • School Contact Person's Name:
  • School Contact Person's Position:
  • School Contact Person's Email:
  • Number of days absent in the current academic year?
  • days absent out of school days.
  • Number of days absent in the last academic year?
  • days absent out of school days.
  • Please provide a detailed overview of most recent school attendance/absenteeism:
  • Please provide a detailed overview of previous school(s) attendance/absenteeism:
  • Previous school(s) attended (please include contact information):

Describe Interventions Attempted

  • Please select the interventions attempted:
  • Home School Community Liaison
  • School Completion Programme
  • Other Interventions:
  • What resources have been allocated to meet young person’s needs?
  • Have parents engaged with any support/resources? (Please give details)
  • Has the young person engaged with these interventions? (Please give details)
  • Does this child have a diagnosed Special Educational Need?
  • Has this child been assessed (or is assessment pending) by the National Educational Psychological Service?

Reason for Referral

  • Please select at least one of the following reasons for the referral:
  • Anxiety
  • Behavioural
  • School Phobia
  • Social Phobia
  • Medical (with Diagnosis)
  • Medical (without Diagnosis)
  • Other
  • Please give more details:
  • Length of time EWS is involved with child/family:
  • Efforts made to support school attendance:

Home Tuition

  • Is the young person entitled to Home Tuition?
  • Has Home Tuition been applied for?
  • Was Home Tuition Granted?
  • Was Home Tuition Availed Of?
  • Please evaluate the Home Tuition:

Other Agencies

  • Do you have any knowledge of other agencies involved with the family?
  • Are you aware of any child protection or welfare concerns?

Medical Information

  • Please provide any relevant medical information about the young person below:

Other Relevant Information

    • Are there any Health and Safety issues that iScoil should be aware of?
    • Does the young person have access to the following technology?
    • Give as much detail as possible and specify if the internet connection is broadband, mobile broadband etc.
    • Please note that tablets are not considered a suitable means for a young person to access iScoil.
  • Internet Connection?
  • PC?
  • Laptop?


  • Do you accept that this young person would be a suitable candidate for iScoil?
  • Referrer's Name:
  • Referrer's Position:
  • Referrer's Agency:
  • Referrer's Phone Number:
  • Referrer's Email:

Once submitted, you will have the opportunity on the next page to attach any supporting forms, documents or reports that you feel are relevant.