Ealing Request for Statutory Assessment Of

ERSA FORM

Ealing Request for Statutory Assessment of

Education, Health and Care Needs for children and young people age 0-25

Name of child/ young person:
DOB:
Education setting / school or home:
Year Group:
Date of request:

This request should be discussed as part of the SEN Support planning meetings in school or setting, so the child / young person and family are involved in the planning and agree to the request.

If there is already an EHAP (Early Help Assessment and Plan) that contains enough information, this should be used to request for Statutory Assessment.Prior to submitting the ERSA, thresholds for EHC needs assessment need to be reviewed on Ealing Grid for Learning .

If Statutory Assessment is agreed, the LA’s SEND Co-ordinator will work with the child / young person and family to gather existing reports and ask for new ones where needed.

Professionals involved with the child/young person may be invited to attend a multi-agency meeting with the family to talk through their assessments and to develop the Education, Health and Care Plan.

Further guidance is available on Ealing’s local offer:

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ERSA FORM 2016 - 17

1. Identifying details –the following must be completed in full

Child / young person’s details
First name / Tel
Surname / Mobile
Address / Email
Postcode / GP name
Gender / GP address
Date of birth / Date of arrival in UK (where relevant)
Child/ young person’s first language
Family’s religion
School/ setting (name and address & contact details (telephone & email)
Start date
Names and locations of other schools attended
Parent/ carer details (1)
First name / Email
Surname / Tel
Address (if different from child/young person) / Relationship to child/ young person
Postcode / Parental responsibility
Is an interpreter required for meetings? / Parents first language
Parent/ carer details (2)
First name / Email
Surname / Tel
Address (if different from child/young person) / Relationship to child/ young person
Postcode / Parental responsibility
Is an interpreter required for meetings? / Parents first language
Other adults with responsibility for the child/ young person (3)
First name / Email
Surname / Tel
Address (if different from child/young person) / Relationship to child/ young person
Postcode / First language
Is an interpreter required for meetings?

2. Which agencies or professionals are currently involved or have been involved recently

(For example: educational psychologist; health professional)

Agency / Name of professional currently involved / Employer, address, email and telephone number / Dates of involvement / Report attached
☐ /
☐ /
☐ /
☐ /
☐ /
☐ /
☐ /
☐ /

2.1Please tell us why you are asking for an assessment of Education, Health and Care needs.

2.2How has the child/ young person been involved?

Learning Journal / ☐ / All About Me / ☐ / Pupil Profile / ☐ /
Target setting / ☐ / Communication Passport / ☐ / SEN Support Plan Review Meeting / ☐ /
Questionnaires / ☐ / Programme Designs / ☐ / After school programme / ☐ /
Participation in wider school life / ☐ / Other

2.3How have the parents/carers/family been involved?

Home School Contact Book / ☐ / Programme Designs / ☐ / SEN Support Plan Review Meeting / ☐ /
Target setting / ☐ / Parents Evenings / ☐ / Timetabling for child / ☐ /
Questionnaires / ☐ / Recruitment of support staff / ☐ / Other

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ERSA FORM 2016 - 17

3. Child/ young person

The child/ young person should be supported appropriately so their interests and aspirations are central to the Plan. Use child / young person centered and creative formats. For children and young people with delayed communication skills or other needs, consider using pictures or other visual prompts to enable them to indicate their preferences. Where possible this section should be signed by the child/ young person.

What is important to me?

My journey so far:

What’s working well?

What’s not working so well and what I’d like to change?

My dreams, aspirations and hopes for the future:

How I need to be supported to be heard and take part in making decisions:

Anything else that you would like to say?

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ERSA FORM 2016 - 17

4. Parent / Carer views

What is going well now?

What’s not working so well?

What does the child / young person enjoy?

What are your aspirations for the future?

What are your views on this request for assessment and the support put in so far?

If your child is due to start school soon, which school would you prefer and when would you like them to start?

Is there anything else that you would you like to say or any further information you would like included?

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ERSA FORM 2016 - 17

1. Special Educational needs summary - this section to be completed by the education setting.

Summary of your main concerns about the child/ young person’s special educational needs:
Please summarise the child/ young person’s strengths and special education needs using the SEN categories: cognition and learning; Communication and interaction; Sensory and/or physical; Social, mental and emotional health.
Achievements and progress

1. Please summarise progress made in the last year and over key stages.
2. Attach the evidence you have used in your setting to show progress.

What’s working well?

1. Give a summary of the interventions used and how effective they have been
2. Attach a provision map and/or the child/ young person’s SEN Support Plan. This should show: baseline measures, provision details, costs and the impact of provision on progress and outcomes.

Attendance – please comment on the child/ young person’s attendance and any action taken.

1. Please describe any strengths and health needs that have been identified and how they are being met.

1. Please describe any strengths and social care or family support needs that relate to the child/ young person’s special educational needs and how they are being met.

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ERSA FORM 2016 - 17

1. Attachments

Please list evidence, reports or assessments that support your request

Title of evidence/ reports/document / Date / Reason for including it
A
B
C
D
E

1. Referrer

This request (ERSA) was completed with the family and young person by:

Referrers Name
Organisation
Contact details:phone + email
Date
Signature

1. Parent /carer / young person’s consent for sharing information

Before signing, parents/ carers and young people should read the information on page 9 that explains what they are being asked to consent to and sign for.

1. I agree to this request to Ealing Council to carry out an education, health and care needs assessment

Signature(s): Date:

NAME: Relationship to child:

1. I understand that if an education, health and care needs assessment is agreed, information will be shared with professionals involved with my child/me to support the assessment and planning process. This will include information provided by the school or educational setting, assessment by an educational psychologist, classroom observation and report; medical assessment and health care reports, information from social care or family support services and any other information and reports that are relevant to the needs of child/ young person.
2. I understand that independent, impartial agencies, as referred to in the Consent Table on page 11, may contact me by telephone if the education, health and care needs assessment isagreedto offer free impartial advice.
3. I have discussed with the local authority the information that I am happy for them to share with other agencies and understand that it will be shared using the locally agreed protocols for information collection, management and confidentiality.

I give my consent / permission for (please tick):

Consent Table
Amedical examination,an educational psychology assessment and a classroom observation as part of the assessment process. / ☐ /
A speech and language, occupational or physiotherapy assessment or other assessment if required. / ☐ /
The Clinical Commissioning Group(CCG) to be informed that a request for assessment has been received and if an Education, Health and Care Plan is issued. / ☐ /
A copy of the EHC Plan to be sent to the Designated Clinical Officer for Ealing and to my GP. / ☐ /
A social care assessment to be carried out if required. / ☐ /
The LA to sharemy contact details with Ealing’s independent impartial family services (web links:ISAIDContact a Family). / ☐ /
The LA to contact me by email using their secureemailing system for electronic communication. / ☐ /

Signature(s): Date:

NAME: Relationship to child:

Please note that a copy of this form must be given to parent(s)/carer(s) / young person and all the enclosures made available to them on request.

CHECKLIST

Has the parent/carer and child/ young person been involved in the request? / ☐ /
Have you filled in all sections of the form? / ☐ /
Have you attached relevant reports and evidence / ☐ /
Is there evidence of the baseline measures, the current SEN Support plan, how the funding has been used and the impact? / ☐ /
Is all the information up to date and recent? / ☐ /
Is there evidence of educational progress over the last 12 months or more? / ☐ /
The guidance & thresholds for EHC needs assessment have been reviewed on the Local Offer / ☐ /

Please do not include the following documentation:-

-Confidential information such as Child Protection case conference notes or professional correspondence without the author’s permission.

-Originals of documents.

-Information that includes the names of other children or young people.

-Full behaviour logs (where applicable an analysis of behaviour should be submitted)

PLEASE NOTE:ALL sections of the request MUST be completed and relevant information attached otherwise it may be returned. The information will be used to inform the EHC plan or SEN support Plan.

Please return the completed ERSA to:

As an alternative you can send the ERSA via post to:

Ealing Service for Children with Additional Needs

SEND Assessment Service

1st Floor

Carmelita House

21-22 The Mall

London W5 2PJ

Ethnicity Description / Code / Tick
Afghan / OAFG / ☐ /
African Asian / AAFR / ☐ /
Any other Black background /

BOTH

/

☐

/
Any other Mixed background / MOTH / ☐ /
Arab / OARA / ☐ /
Bangladeshi / ABAN / ☐ /
Black – Caribbean / BCRB / ☐ /
Black – Ghanaian / BGHA / ☐ /
Black – Nigerian / BNGN / ☐ /
Black – Somali / BSOM / ☐ /
Chinese / CHNE / ☐ /
Gypsy – Roma / WROM / ☐ /
Indian / AIND / ☐ /
Information Not Yet Obtained / NOBT / ☐ /
Iranian / OIRN / ☐ /
Iraqi / OIRQ / ☐ /
Japanese / OJPN / ☐ /
Latin/South/Central American / OLAM / ☐ /
Pakistani / APKN / ☐ /
Other Asian / AOTA / ☐ /
Other Black African / BAOF / ☐ /
Other ethnic group / OOEG / ☐ /
Refused / REFU / ☐ /
Traveler of Irish Heritage / WIRT / ☐ /
White / WOTW / ☐ /
White and Asian / MWAS / ☐ /
White and Black African / MWBA / ☐ /
White and Black Caribbean / MWBC / ☐ /
White - British / WBRI / ☐ /
White Western European / WWEU / ☐ /
White – Irish / WIRI / ☐ /
White Eastern European / WEEU / ☐ /

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