Applying for a personal budget:

Applications will be assessed in line with the Councils Policy. You should refer to the policy when making your application. You can access the policy online at or by calling 020 7525 5256.

If you would like assistance to complete this form you can contact the SIAS Team on 0207 525 5256. This team can help you to complete this form on the phone or at the drop sessions at Sunshine House.

Do I qualify to apply for a personal budget?

Please ensure you complete all the relevant sections to ensure your application is processed correctly. Applications for personal budgets will be assessed under the following criteria:

Section 1: Child/ Young Person’s Details

Please complete in capital letters

Male Female (Please circle)

Child/Young Person’s Surname:

Forename:

Date of Birth:

Address:

School/provision details:

Date of most recent EHC plan (if applicable):

Section 2: Further Information on Special Need or disability

Please detail the provisions for which the personal budget is required and why you would like it delivered this way. Be sure to address every aspect of the criterion you are applying under as defined in the relevant sections of the policy.

Please continue on a separate sheet if necessary

Which category are you applying under:

1 / I’m applying for a personal budget following an initial EHC needs assessment / Yes / No
2 / I’m applying for a personal budget following a statutory review of an existing EHC Plan, or transfer process from a statement to an EHC Plan / Yes / No
3 / I’m applying for a personal budget from social care / Yes / No
4 / I’m applying for a personal budget from health services / Yes / No
5 / I’m applying for a personal budget from the travel assistance service / Yes / No
6 / Are there any other exceptional circumstances that you would like the Council to take into consideration? (Please provide details and any evidence) / Yes / No

Section 3: Parents/Carers’ Details

Title:

Surname:

Forename:

Family Address:

Is this the child’s permanent address?

YES NO (Please circle)

Email Address:

TelephoneNumber:

Section 4My Declaration:

You must read this section carefully before signing this form.

  • The information on this application form is true and correct to the best of my knowledge.
  • I have enclosed all the necessary supporting paperwork as required.
  • I have read the Southwark Personal Budgets policy and understand that the child/ young person’s application will be judged strictly in accordance with the policy.
  • I understand that the Special Education Needs Department may need to verify the evidence I have provided and therefore consent to contact being made with the author of my supporting documents.
  • Personal information contained in this form will be held on a computer and is therefore subject to the provisions of the Data Protection Act 1998.

Signed:

Name:

Date:

Please complete and return this form with the necessary documentation to:

Southwark Council

Children and Adult’s Services

PO Box 64529

London SE1P 5LX

Phone: 0207 525 0843

E Mail:

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