statutory school request for ehc needs ass form working web view · 2018-01-07request...

Community Learning & CommissioningNovember 2017

Statutory School age request/contribution to an Education Health and Care Needs Assessment

Request must be typed/word processed. Please ensure that you have read the EHCP Application guidance provided before completion.

Please tick whether this form is:

Request for an EHC Needs Assessment:

OR New or Updated Submission of Statutory Advice:

New Updated

Date of Request: Date of updated submission:

1 Child/young person’s personal details 1a Names/personal details

Child’s/Young Person’s Legal Surname: Forename(s):

Surname also known as (if applicable):

Prefers to be known as:

Date of Birth: Gender: Male Female

Address of Child/Young Person(including postcode):

1b Current educational setting & care status

Setting name:

Setting address (& postal Address if different)(including postcode):

Setting Tel No:

Date of admission to current Setting: NCY/Preschool:

Is the child placed in their chronological year? Yes No* * If No, in which year?

Child in Care? Is the child/young person subject to a care order or any other court order? Yes* No

* If Yes, give details of the nature of the order and the name/contact address/telephone of the allocated Social Worker:

1c Parent/Carer/Other details (names and addresses of ALL persons who hold parental responsibility under Children & Families Act 2014). Attach a separate sheet if necessary

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PARENT/CARER DETAILS 1 PARENT/CARER DETAILS 2

Title: Title:

Family Name: Family Name:

Forename(s): Forename(s):

Address (including postcode):

Address(including postcode):

Telephone(Home):

Telephone(Home):

Telephone(Mob or Work):

Telephone(Mob or Work):

Email address: Email address:

Relationship Relationship

State any barriers to communication eg EAL, hearing impairment?

State any barriers to communication eg EAL, hearing impairment?

1d Language & religion of child: Home language(s):

Preferred language:

Religion: Interpreter needed? Yes No1e Other information relevant to child’s needs:Has a Common Assessment Framework (CAF)/Early Support Plan been completed on this child/young person? Yes* No

* If Yes, please name the keyworker and attach a copy of the CAF/Early Support Plan (having obtained parental agreement to forward the form):

CAF Attached?

Yes NoHas the child/young person had any support from Children’s Social Care in the past year? Yes* No

* If Yes, name the social worker involved for Children’s Social Care. Parents/carers will give permission to share information by signing section 8b at the end of this form.

Name/tel no of Social Worker:

Has the child/young person received short breaks during the past year? Yes No

Is the child/young person from a Services (Armed Forces) family? Yes No

Is the child/young person from a Traveller family? Yes No

1f Views, interests, background and communicationChild/young person’s views, interests, skills and hobbies:Please include information on things that are important to the child/young person such as their favourite activities, hobbies they like doing and their overall general interests.

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From Year 9 onwards: Details of the child/young person’s views and wishes on preparing for adulthood

Education, employment and the world of work Being part of the community, family life and friendships

Healthy living and positive wellbeing Independent living and housing

Parent/Carer views, wishes and feelings:

Child/young person’s background and history including factual information about the family context (Include information that is relevant to the child having SEND ie delayed development/milestones, significant life or family events, early indicators of having a SEND)

How to communicate with and engage the child/young person:

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2 Attainment and progress 2a Attainment in main curriculum areas Complete table to record long-term attainment/ ability assessment/milestones using the Age-Related Expectations, National Curriculum, P Scales, GCSE Unsupported Levels and indicating end of KS or teacher assessment. Provide age equivalent or standardised scores if you have these. Put TA, if Teacher Assessment.

Attach more detailed information if required regarding tracking, e.g. use of CASPA in special schools

Equivalent format can be provided as long as it shows the child’s attainment over time

Subject Area Two years ago One year ago Current Year Comments on progress

Include subjects below as appropriate

Date : Date: Date: Provide explanation of what these levels/grades show

Long term attainment, providing Age Equivalent Scores (last three years)

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Two years ago One year ago Current Year

Skill Name of test Date Age at

Test

Age Equivalent

ScoreName of

test Date Age at

Test

Age Equivalent

ScoreName of test Date Age at

TestAge

Equivalent Score

Reading

Spelling

Long term attainment providing Standardised Scores (last three years)

Two years ago One year ago Current Year

Skill Name of test Date Standardised Score Name of test Date Standardised

Score Name of test Date Standardised Score

Reading

Spelling

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2b Progress in main curriculum areasComplete table to record long-term progress using the National Curriculum/P Scales/GCSE Unsupported Levels and indicating end of KS/teacher assessment.

Equivalent format can be provided as long as it shows the child/young person’s Progress over time.

Date Assessed Subject/ Area of Learning Progress and future targets –Include information that cannot be measured through standardised testing such as improvements in behaviour, confidence, self-help etc

Progress in Reading, Writing and Maths - Please complete the table below to detail areas of strength and need

Strengths: Areas of need:

Reading

Writing

Maths

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Please tell us how the child/young person communicates and interacts with others. Please clearly state what the child/young person’s strengths are in this area, as well as needs.

Please tell us how the child/young person feels and gets on with others. Include areas of strength as well as any needs.

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2c Broad areas of need & support

Explain how the child/young person meets the criteria for EHC needs assessment with reference to the Code of Practice broad areas of need and support (include strengths and needs).Cognition and learning:Add here any general information in addition to Section 2A Attainment & Progress tables above

What are the child/young person’s strengths?

What are the child/young person’s needs that impact on learning?

How do the need impact on the child/young person?

Communication and interaction:

What are the child/young person’s strengths



Social, emotional and mental health:




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Sensory and/or physical needs:




Independence and self-help:


What are the child’/young person’s needs/barriers?

How do the needs/barriers impact on the child/young person?

Provide a summary of why you believe “the child or young person has or may have special educational needs * such that “it may be necessary for special educational provision to be made for the child or young person in accordance with an EHC plan”. (CfA, 2014- subsection 8).

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Attendance For children in reception, please list the name and dates of all schools attended in the last 12 months along with percentage attendance levels for the last 12 months:

School/setting name(start with current school

then list previous schools in last 12 months)

Attendance from date: Attendance to date:

Attendance figures (including percentages) over the last three terms (including the present term).

ATTACH ATTENDANCE PRINTOUT*Autumn/Spring/Summer

Term 20……(*indicate relevant term)

*Autumn/Spring/Summer Term 20……

(*indicate relevant term)

*Autumn/Spring/Summer Term 20……

(*indicate relevant term)

Has the child had any fixed term exclusions during the past year? * If Yes, please list dates and reasons below:

YES* NO

Reasons for exclusions:

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3 Health and Social Care needs3a Health Needs

Physical and mental health, physical development and sensory needs. State how these needs impact on the child’s ability to learn, make progress and access the curriculum. Include evidence of medical diagnosis/conditions

Areas of strength:

Areas of need/challenges:

Other health needsHealth conditions that do not impact on education or learning

Areas of strength:


Self-help and skills for independence related to health needs Such as medical conditions that impact on ability to dress, toilet etc:

Areas of strength:


3b Social Care or Early Help needs

Social Care needs (relating to SEN)Include information on Social Care or Early Help Services that may be involved with the child/young person/family.

Areas of strength:


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4 Current provision (specific/quantified/costed) and measured impact

4a School/Early Years SEN support Attach the SEN SUPPORT PLANS (SSP)SSP Start Dates SSP Review Dates

Provide dates for the two most recent SEN Support Plan (SSP), or equivalent documents (ILP, IEP etc) and reviews. Attach copies ensuring they are signed, dated and there is evidence of reviewing outcomes. They should include detail of current provision and how you are implementing the Graduated Approach (ASSESS, PLAN, DO, REVIEW) which is regularly reviewed to reflect the child/young person’s needs.

4b Current support arrangement, costed provision and observation of progress Schools have delegated funds to support pupils with additional needs, including those with SEN and disabilities. Please outline below any provision made from either delegated funds or Local Authority resources to support the child/young person’s needs.(indicate current source of additional funding)

Additional Support funding

High Needs funding

School’s delegated funds

Total amount of support currently funded = £

Details of the targeted/specialist support provided for the child funded by setting or Local Authority, e.g. Outreach Service, Inclusion Services and Health provision. Only include support that is additional to, and different from, ordinary differentiated classroom/setting arrangements. Complete table below and indicate costs.

Support/Provision delivered

(1:1, groups, whole class)

Desired outcomes sought

(eg child will be able to take turns in play)

Strategies implemented

Frequency, duration and by

whom

Start date-end/review

date

Actual outcomes and impact made

Costs for this child(divide group

costs by number in group)

Description of supporting evidence(eg outcome/target on SSP

relevant to desired outcome)

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4c Progress in response to provision Describe the overall impact of the support/provision provided. Has the provision supported the child to make progress towards their outcomes? Why is additional support beyond SEN support now needed? Under paragraph 9.3 of the SEND Code of Practice 2015, in a very small minority of cases children or young people may demonstrate such significant difficulties that a school or other provider may consider it impossible or inappropriate to carry out its full chosen assessment procedure. For example, where its concerns may have led to a further diagnostic assessment or examination which shows the child or young person to have severe sensory impairment or other impairment which, without immediate specialist intervention beyond the capacity of the school or other provider, would lead to increased learning difficulties.

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4d How have Specialist Support Services or outside agency input been used to develop provision – graduated response?Examples of services/agencies are Educational Psychology Service, Behaviour Support Service, Hearing & Vision Support Service, Educational Welfare Service, Children’s Social Care, Therapists, Tuition Service, EMTAS, CAMHS, Other.

Involved since (date)

Name of each professional involved/contact details

Service/ Agency

Recommendations Action by setting – targeted intervention

Outcome achieved for child/young person

Specialist training or professional development (PD) your setting/school has undertaken in order to support the child. How has this impacted on the child/young person’s progress?

Description of training/PD

Date undertaken Comments on how the training/PD has impacted on the child/young person’s progress

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5 Desired outcomes and aspirations

5a Briefly state the aspirations for the child/young person. These should be developed with the Parent Carer/Child/young person and describe the long-term hopes/dreams/wishes of the child/young person.

State the desired outcomes The expected benefit or difference made to the child/young person as a result of a support being put in place. These should be developed with the parent carer and, where appropriate, the child/young person. Phrase these in terms of what the child will be able to do with additional support. (See Bournemouth SEND EHCP guidance for help with developing outcomes)

State any shorter-term targets that have been discussed with the parent/carer and, where appropriate, the child/young person.

How have you involved the child/young person’s parent/carer and, where possible, the child/young person, to develop SEN support for the child and complete this form.

6 Ranking of identified primary and other needsSee Code of Practice 2014, along with the Bournemouth Special Educational Needs Criteria

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6a Indicate the PRIMARY NEED with a 1 and, if more than one need, please rank the others in terms of significance (you should discuss this with your Educational Psychologist):

Need Ranking Please indicate below any medically diagnosed conditions (eg ADD, ADHD, Cystic Fibrosis, Downs, MS, MD, Epilepsy, etc)

Communication and interaction:

Autism (including Asperger’s syndrome) (ASD)

Speech, Language & Communication Difficulties (SLCN)

Cognition and learning:

Moderate Learning Difficulties (MLD)

Severe Learning Difficulties (SLD)

Specific Learning Difficulties (SpLD)

Profound and Multiple Learning Difficulties (PMLD)

Social, emotional and mental health difficulties:

Social, emotional and mental health difficulties

Sensory and/or physical needs:

Physical Difficulty (PD)

Hearing Impairment (HI)

Visual Impairment (VI)

Multi-Sensory Impairment (VI)

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7 Checklist of essential documents attached

Document RequiredDocument Attached?

YES

Document Attached?NO

please indicate why document is missing

7a

The Child’s One Page Profile or similar document

Child’s/Young Person’s View – the child/young person should be encouraged to contribute. This may be done either through the school or via the parent in a format appropriate to the child’s/young person’s needs – either a One Page Profile or similar document:

7b

The Parent/Carer’s ‘My Child, My Story’ or similar document

The parent(s)/carers should be encouraged to submit a written contribution detailing their perception of their child’s difficulties and needs. Copies of a leaflet ‘My Child, My Story’ can be obtained from the SEN Team to help them do this. The SEND Information Advice and Support Service (SENDIAS) will also help parents to write their contribution.

7c2 most recent SEN Support/IEP/ILP plans and Reviews at SEN Support (or the provision map with evidence of impact)

7dCopies of assessment information, e.g. reports or letters from SENCOs, test results

7e Evidence that the Educational Psychologist has been involved in planning the interventions and reviewing progress (must be within the last six months), i.e. (Joint Action Plan and Joint Review forms)

7f

Reports or Records of Involvement from other Local Authority Inclusion Services, Children’s Social Care, Outreach and from Health (e.g. Speech & Language Therapist (SaLT); Physiotherapist, Occupational Therapist, Paediatrician, Psychiatrist)

7gPastoral support plans, where appropriate

7hBehaviour Management Plan/Positive Handling Plan, where appropriate

7i Risk Assessment, where applicable

8 AUTHORISATIONS

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8a Headteacher/Manager/Principal

I confirm that, having followed the procedures outlined in the Code of Practice, the setting is making this request for EHC Needs Assessment.

I confirm that the Educational Psychologist is aware of this request and has been involved in supporting the setting to meet this child’s/young person’s needs.

I have enclosed evidence of Consultations, Records of Involvement from relevant professionals and have gained parental consent to share these along with evidence of graduated response.

Headteacher/ Manager / Principal:

Name (BLOCK CAPITALS): Signature: Date:

8b Parent(s)/carer(s)

I consent to this information being used as a request for, or a contribution to, an EHC Needs Assessment. If the request is agreed, I consent to appropriate agencies including Education Services, the Health Service and Social Care, sharing and discussing relevant information relating to my child.

I confirm that I consent to psychological and medical reports being obtained for my child if the process goes ahead.

Data Protection At 1998 The Data Controller for Bournemouth Borough Council is Head of IT Services. This information is being collected for the purpose of administering referrals, but may be used for the wider purpose(s) of the provision of education services. When you complete this document, you are providing your consent for the Council to hold and use this personal information for these purposes. The information you provide may be disclosed to: other internal directorates, those with parental responsibility, healthcare, education establishments, other LAs, the DCSF, the diocesan boards, courts and tribunals.

Parent(s)/Carer(s)

Name(s) (BLOCK CAPITALS) and Relationship to child/young person:

Signature: Date:

This form was developed using a Pan Dorset approach. Information provided may be processed electronically and used for administrative, audit and quality

assurance purposes.

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9 Sending this form9a How and where to send this form

Please send your fully completed form and attachments as follows:

1. Hard copy via post/internal courier to The SEN Team, Floor E3, Town Hall, Bourne Avenue, Bournemouth, BH2 6DY

2. Via email - YOU MUST USE SECURE EMAIL as follows:

a. You may send this form electronically, by attaching to email and also scanning the Authorisation pages and attachments. Please put in the Subject Line either: Request for an EHC Needs Assessment OR Submission of Statutory Advice

b. If sending from a bournemouth.gov.uk email address, simply send to: [email protected]. This will automatically be secure.

c. If sending from other email addresses, you will need to send via a Clearswift account – a secure website portal where you set up an account with your email address and password. If you don’t have a Clearswift account set up with us, please call the SEN Team on 01202 456162.

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mailto:[email protected]

statutory school request for ehc needs ass form working web view · 2018-01-07request...

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