WORKING DRAFT

EHCP Personal Budget Request Form
Please ensure that you have read the guidance provided before completion.
Please tick whether this form is:
A Personal Budget for a new EHCP: / OR a Personal Budget Following an annual review:
Date of Request: / Date of updated submission:
1Child’s/Young Person’s personal details
1aNames/personal details
Child’s/Young Person’s
Legal Surname: / Forename(s):
Surname also known as
(if applicable): / Prefers to be known as:
Date of Birth: / Gender: / Male / Female
Address of Child/Young Person
(including postcode):
Name of education setting the child/young person will attend:
If Young Person has reached the end of Y11 or is older, do they want to be involved and contacted directly to discuss the personal budget? / Yes* / No
If YES, add tel no/mob no, email & address (if different from above):
If NO, add details of the young persons nominated representative or appointee (name, contact number, email and relationship to the young person)
All requests for Personal Budgets must be linked to achieving the Outcomes agreed in the EHCP. Please write below the Outcomes/Needs for which a Personal Budget is being requested.
For each Outcome/Need, state how the Personal Budget would be used to support success, how you will meet the need and how you will monitor success.Include any estimated costs of provision (if known).
Outcome / Proposed Personal Budget Provision / Cost
Is any of the proposed provision to be delivered within the education setting? / Yes No
If Yes, has this been discussed with the head/lead of the education setting? Please provide a brief overview of the discussion.
If successful I would like the personal budget to be managed by: / Direct payment to the young person/parent carer
Direct Payment Managed by a third party
I would like to discuss further how to manage
the Personal budget
I understand that in order to process this request Bournemouth Borough Council will need to access my child’s EHC Plan and associated papers and may need to make enquiries of relevant professionals across agencies to obtain information and seek approvals before a budget request can be agreed.
Please see guidance for further information. / Signature:
Date:
I am ( please delete) the child/Young Person/Parent Carer/Nominated person
Please send your fully completed form and attachments as follows:
  1. Hard copy via post/internal courier to The SEN Team, Floor E3, Town Hall, Bourne Avenue, Bournemouth, BH2 6DY
  2. Via email - YOU MUST USE SECURE EMAILas follows:
  3. You may send this form electronically, by attaching to email and also scanning the Authorisation pages and attachments. Please put in the Subject Line either: Request for an EHC Needs Assessment OR Submission of Statutory Advice
  4. If sending from a bournemouth.gov.uk email address, simply send to: . This will automatically be secure.
  5. If sending from other email addresses, you will need to send via a Clearswift account – a secure website portal where you set up an account with your email address and password. If you don’t have a Clearswift account set up with us, please call the SEN Team on 01202 456162.

Personal Budget Request Form Working Draft Nov 17 Page 1