Early Years SENDIP Request Form

for children with Special Educational Needs and Disabilities

Section 1) Child and Family details

Child’s Name / DOB / Gender
Parents/Carers Names / Parents / Carers Address
Contact Number / Postcode
Child characteristics: / Family characteristics or affected by:
☐Adopted child / adopter family
☐Cared for by extended family
☐Within ‘Connecting Families’ initiative
☐Child in Need (CHIN)
☐On Child Protection Plan (CP)
☐Looked after Child (LAC) / ☐Lone parent
☐Teenage mother
☐Low income
☐Parental disability
☐Adult mental health issues
☐Domestic abuse
Are the family claiming DLA for the child (Yes / No) – if yes include proof / ☐Yes ☐No
Is the child already attending an Early Years Setting? / ☐Yes ☐No
Preferred or Current Setting/s Name / Current Hours at Setting
Required Hours at Setting

Section 2) Request details

2 Year Placement & Inclusion Support / ☐ / 3-4 Year Inclusion Support / ☐
Referrer Name / Referrer Address
Job Title
Contact email address / Postcode

Section 3) Informationrequired as part of request – Information must be dated within last 6 months

The information below is essential and the request will not be considered unless all information is provided / Tick to confirm information included in request
One Page Profile or section four completed / ☐
Completed ‘My Plan’ with outcomes
(only required if a child is already attending an Early Years setting) / ☐
Early Years Child Progress Tracker / ☐
Specialist Reports - e.g. Paediatrician, Speech and Language, Occupational Therapy, Sensory Support etc. / ☐
Early Help Assessment –e.g. Common Assessment (CAF) or equivalent
(not required if Social Care assessment in place) / ☐
Additional relevant information – e.g. Targeted Outcome Plans, Inclusion Plans, Risk Assessment, Being Kept in Mind Form etc. / ☐

Section 4) Child’s Voice and Parent / Carers views– Please complete or attacha one page profile

Child’s Voice
What others like and admire about me / What is important to me? / What is important for me?
(My needs and how best to support me)
My family’s thoughts

Section 5) Parental consent – Request will not be considered unless signed by parent / carer

Parents / Carers – Please confirm the following / Yes / No
I have participated in this request / ☐Yes ☐No
I am happy for this information to be shared with relevant professionals / ☐Yes ☐No
Children’s Centre Support
To ensure you receive details about support available to you, your details and summary information about your child’s needs will be shared with your local Children’s Centre. Please tick if you do NOT want this. / ☐
Parent / Carer Name / Parent / Carer Signature / Date
Referrer Name / Referrer Signature / Date

Please return this form to the following address:

Early Years Special Educational Needs, Disability and Inclusion Team (SENDIT)

Bath and North East Somerset Council

Lewis House

Manvers Street

Bath

BA1 1JG

Tel – 01225 395608

Email –

This document can be made available in a range of languages, large print, Braille, on tape, electronic and accessible formats from the Family Information Service (FIS):

Tel: 01225 395343
Fax: 01225 395211
Textphone: 07980 998906

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