GLOUCESTERSHIRE ADVISORY TEACHING SERVICE

REQUEST FOR ADVISORY TEACHER INVOLVEMENT
Child Information
Full Name of Child: / DOB:
Male/Female: / Age: / Year Group:
Home Language: / Ethnicity:
Names of Parents/Carers:
(if child is in care please also state who has parental responsibility) / Contact Details:
Home Tel:
Mobile:
Email:
Are you happy for the Advisory Teaching Service to use secure e mail (Egress) to send information about our visits / Please circle below
Yes No
Pupil’s Address:
Post Code:
Is the child in the Public Care?
Yes No / Additional Adults with Parental Responsibility:
Name:
Address:
Is the child on the Social Communication Pathway?
Yes No
Child/Family CAF? Yes/No / Date started: / Lead professional:
School Information
Current School/Setting: / Date of Entry:
Address :
phone number:
contact e mail address:
Previous school/pre-school settings:
Advisory Teacher Involvement
What outcomes do you hope will be achieved as a result of Advisory Teacher involvement?

X

X

Once completed this form should be returned to your area base including supporting evidence from the setting

INFORMATION AND CONSENT FROM PARENTS/CARERS

BY SIGNING THIS FORM I AGREE TO THE FOLLOWING:

·  I give consent for [ ] Advisory Teacher to become involved with my child.

I understand this may involve a range of different activities including consultation with school staff and other professionals, observation, direct work or testing with my child, including talking to my child about their views relating to their education, and attendance at review meetings.

·  I have been given a copy of the Gloucestershire Advisory Teaching Service Information for Parents and Carers.

·  I understand that I will be given a copy of any written Advisory Teacher’s Records and that a file will be opened for my child and that this will be kept in a secure place.

·  I give consent for other copies of other services’ reports to be made available to support this request.

·  I give consent for this form to be shared with other professionals to determine whether different types of support may be available to my child.

·  I have read the data protection information at the bottom of the page.

Additional parent/carers comments:

Data Protection Act. This information is being collected for the purpose of determining the educational needs of the named pupil, but may also be shared with other relevant professionals such as teachers, health and social workers etc, to inform their work. The information collected may also be used for the wider purpose of providing statistical data used to assist with monitoring provision and/or determining areas of need in order to target future resources. For further information please contact the Advisory Teaching Service (see leaflet for contact information).

SUPPORTING INFORMATION

Other Agencies Involved:
Specialist / Date Involved / Name of Professional / Tel No: / Letter/Report Attached
Previous Advisory Teaching Service Involvement
Educational Psychology
Pupil Referral Service (PRS), and Behaviour Support
Early Years/Portage
Health Visitor
GP
Paediatrician
Occupational Therapist
Speech and Language Therapy Service
CYPS
Targeted Support Team, CAF, Family Support
Social Worker/Community Family Support Worker
CYPwD Service
Other ( including Team Around the Child meetings)
Checklist to Support Request: NB sections marked with * are mandatory / Tick
*Completed ALL the details on Page 1 and include details of:
*At least 2 x My Plan/ My Plan+/ IEP or Personalised Educational Plans and reviews
Provision Map
Pastoral Support Plans
CAF forms
Reports from other involved professionals
Visual Representations of relevant data e.g. behaviour charts
*Completed EYFS and/or SATs data from your setting or previous settings if necessary
*Information about the interventions you have tried and their outcomes – with reference to Gloucestershire Guidance Booklet (available on SENCOSPOT)

Please remember to attach copies of My Plan/My Plan+/IEPs/Personalised Learning Programme/Provision Maps/CAFs/ highlighted sections from Gloucestershire Intervention Guidance/ or any other documentation about existing special needs support, planning and intervention to this request. Full information will inform any future planning for Advisory Teacher consultation or involvement. Thank you.

Advisory Teaching Service (Gloucester)
4-6 Commercial Road
Gloucester
GL1 2EA
01452 426955
/ Advisory Teaching Service (Cheltenham)
Battledown Centre
Harp Hill
Cheltenham
GL52 6PZ
01452 324376

Advisory Teaching Service (Stroud)
Redwood House
Room F01
First Floor
Beeches Green
Stroud
GL5 4AE
01452 583728
/ Advisory Teaching Service (Forest)
Dockham Road
Cinderford
Glos.
GL14 2DB
01594 823102

The completed form should be returned to your local base

Request for AT Involvement 1 DS/May 17