Specialist Teachers for Inclusive Practice

South East Surrey Commissioning Form

Name of School:

Head Teacher:

Business Manager: E Mail / Telephone:

School Contact: E Mail / Telephone:

Band: Hours:

Reviews:

Pupils Name Please Tick One Hrs LLS or BS(STIP to

complete teachers name)

Date Agreed

(to be completed by

STIP)

Core Traded

New priorities:

Service(include name if individual pupil

referral)

Please Tick One Hrs LLS or BS(STIP to

complete teachers name)

Date Agreed

(to be completed by

STIP)

Core Traded

Total number of Core Hours:

Total number of Traded Hours:

Please order additional hours using the new Service for Schools online ordering system: http://servicesforschools.surreycc.gov.uk/

Please use our new web page on the Surrey County Council Website to download referral forms: https://www.surreycc.gov.uk/schools-and-learning/teachers-and-education-staff/educational-advice-and-support-for-teachers/specialist-teaching-teams/south-east-specialist-teachers

*Referrals for all new priorities must be received 10 working days before the agreed date for the STIP visit. Where referrals are not received appointments may be cancelled.

Signed on behalf of the school by:

Name ________________________ Signed __________________________

Signed on behalf of the Specialist Teachers for Inclusive Practice by:

Name ________________________ Signed __________________________

This form should be returned to:Wendy Mumford, Senior Lead Specialist Teacher, Consort House, 3 – 5 Queensway, Consort House, Redhill, Surrey, RH1 1YB.