Surrey Review Form
Name:
Date of review:
Photo (Optional)/ What people like about me and what I like about myself
One Page Profile Template
What is important to me / How best to support meDate:
My Surrey Review
Name: Date of review:
Further Details
Family name: / First name:Known as:
Date of birth: / Gender:
NHS/NI/ICS/other registration numbers:
Parent/carer names:
Who has parental responsibility?:
LAC status:
Siblings:
Contact address for child or young person:
Contact addresses for parent/carers:
Telephone: / Mobile:
Email:
EHCP coordinator name:
Type and name of education setting:
Year group: / Placed out of year:
Ethnicity: / First language:
Language used at home: / Religion:
Main communication method:
Language interpretation support needed:
GP name and contact details:
Current consultants details:
Other practitioners who are/have been involved (name, email, telephone):
Times that are difficult for me or family to attend appointments:
Barriers that might make it more difficult for me or family to attend appointments:
Other relevant plans:
Other useful information:
Current Education Provider:
Name: / Address:
Contact name: / Contact number:
Education Provider: school/ college / Current banding level or schedule 2, IPA support:
’s story – play, health, schooling, independence, friends and relationships, further education, future plans etc
’s family’s story
More information on how to support and [his/her]family
’s aspirations
’s family’s aspirations for [him/her]
How and [his/her]family have taken part in this plan
1. Who is here?
Record of who attended and did not attend my Review
NAME / Role / Invited / Attended / Report attached?
Yes / No
Who did not attend:
2. Review of One Page Profile: what people like and admire about me & what’s important to and important for me now
Please attach an updated version of the One Page Profile
3. What changes are there to my story or my family’s story which are important to know?
’s special educational needs
4. Please detail any changes to the following areas of needSummary of main special educational needs
More detailed information:
1. Cognition and learning:
2. Communication and interaction:
3. Social, mental and emotional health:
4. Sensory and physical:
5. My current support arrangements
5a. Schools Only
Please attach a provision map:
5b. Colleges Only
Please complete the programme schedule below or where applicable please attach a Schedule 2, Individual Placement Agreement :
Programme:
Qualifications and/or course details: / Additional support required:
6. Review of progress made
What progress has been made against the targets detailed in the EHCP/statement objectives/LDA and programme objectives?
Append current targets and progress measures / assessment used within School.
Current Programme: / Start Date:
End Date:
Qualifications and/or course details: / Expected to achieve qualification by end of programme*: / Grade achieved (if some parts of programme already complete): / Additional support provided:
Yes / No
* If not expected to achieve agreed programme outcome/qualification, please give explanation of what resources you have put in place to achieve outcomes:
7. What is important to and important for me in the future
Please add comments on what outcomes the young person would like to achieve, now and in to adulthood:
8. My Future Destination
Please complete for transition phases only where there is a change in setting:
6th Form School/College:
Course requirements and support arrangements:
Programme: / Proposed Start Date:
Proposed End Date:
Qualifications and/or course details: / Additional support required:
Employment, higher education, independent or supported living:
Please outline details:
9. My new targets and action plan and person(s) responsible
Please redraft and append table E of the EHCP detailing new targets and the arrangements to support these.
10. Statement Changes – For those continuing on a statement only:
Recommended changes to my statement: / YES
Part 1 – changes to my personal details e.g. address/telephone number
Part 2 – changes to my special educational needs
Part 3 – changes to my objectives and provision to meet my special educational needs (link this with the new action plan)
Part 4 – changes to my school
Part 5 – changes to my non educational needs
Part 6 – changes to my non educational provision
11. Personal Budgets
Does the young person/parent wish to request a personal budget? Yes No
If yes please consult: www.surreycc.gov.uk/sendchanges
Have existing transport arrangements been considered in light of this review? Yes No
(where appropriate, independent travel training opportunities should be considered)
12. Recommendations of review meeting
Is this a transfer of a statement to an EHCP?
Resourcing levels will be considered at the resource forum / Yes / No
Is a statutory plan still required?
If the young person or child’s SEN can be supported through core arrangements, then a statutory plan will no longer be needed and ceasing arrangements will be applied. / Yes / No
Does the statutory plan need amending?
It is recommended that you seek updated advice. / Yes / No
Report completed by (Head teacher/SENCo/LA officer) ...... Designation
(Name in capitals)
Signed ...... Date ......
11 Name: Date: