PATSS (Plymouth Advisory Team for Sensory Support)

Request for involvement

PATSS (Plymouth Advisory Team for Sensory Support)

Version 1, August 2014 Not protectively marked

PLYMOUTH CITY COUNCIL

Please complete as much of the form as you can, ensuring that you have the signed consent of the young person’s parent or carer to share information, as this referral may be considered at a Children’s Integrated Disability Service SEND meeting. Please return to:

Advisory Team for Sensory Support, Windsor House, Tavistock Road, Plymouth PL6 5UF

Tel: 01752 668000 Text/SMS 07500 122724 or email

Parent and child details

Child's name Click here to enter name / DOB Date of birth
Parent or carer name Click here to enter name / DOB Date of birth
Address Click here to enter address
Home phone Click here to enter home phone / Mobile phone Click here to enter mobile phone
Ethnicity Click here to enter ethnicity / First language Click here to enter language
Hospital number Click here to enter hospital no / Email address Click here to enter text.

Referrer details

Referrer's name Click here to enter referrer / Designation Click here to enter designation
Phone number Click here to contact number

School details

School Click here to enter school / UPN Enter UPN / Year Enter year
Is there a SEND Plan? Yes ☐ No ☐
Has this student seen their GP or school nurse regarding their hearing/vision? Yes ☐ No ☐

Other services involved with this young person

Name Click here to enter name / Contact Click here to enter contact details
Name Click here to enter name / Contact Click here to enter contact details
Name Click here to enter name / Contact Click here to enter contact details
Name Click here to enter name / Contact Click here to enter contact details

Summary of needs

Click here to enter summary of needs

Outline actions taken to help young person so far

Click here to enter actions taken to help young person so far

Outline the type of support you would like to receive

Please supply as much additional information as possible including relevant reports from other agencies such as psychologist, therapist, paediatrician, audiologist, REI etc

Young person’s view

Click here to enter young person's view

Parent or carer's view

Click here to enter parent or carer's view

Referrer’s view

Click here to enter referrer’s view

I understand that information is recorded about me/my child. I have had the opportunity to discuss the implication of this. Please tick one of the following and sign where appropriate.

1. I agree that personal information about me/my child may be shared between this organisation and other relevant organisations / Name
Signature of child/young person
Date

Signature of Parent/Carer

Date


2. I agree that personal information about me/my child may be shared between this organisation and other relevant organisations except:



/ Name
Signature of child/young person
Date

Signature of Parent/Carer

Date

I understand that the limitations may affect the service that is available. We will not pass on any information without consent, unless we are required by law or we have a statutory duty to do so in order to:
1. Protect you, or, 2. Prevent harm to someone else, or, 3. prevent or detect a crime

3. I do not want my personal information being passed to other organisation / Name
Signature of child/young person
Date

Signature of Parent/Carer

Date

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