Referral for Early Years Inclusion Support

Please fill in this form as fully as possible. This will require a detailed conversation with parents

IF THE REFERRAL NOT COMPLETE - IT WILL BE RETURNED TO YOU.

1. I

Name of child: / Gender: / DOB:
Address: / Telephone no:
Postcode:
NHS number (if known):
Setting name: / Home Language:
Ethnic origin:
Is the child in the Looked After System? Y/N
Year of school entry:
Date of entry to setting: / Mon / Tues / Weds / Thurs / Fri
AM
PM
Sessions attended:
Does the child attend another setting? Please include specialist settings e.g. CDC, Blackmarston, Westfield (If yes, please give details)
Are there any safeguarding concerns? (Please indicate if there is a CAF/Child in Need/ Child Protection Plan in place)
Lead professional (CAF):
Please state the child’s primary additional need (use code below – one only). Choose the one that has the most impact on the child’s learning and development. The code is for data purposes only.
Primary Additional Need Code /
  • SEMH –Social, Emotional and Mental Health
  • CL – Cognition and Learning
  • SP - Sensory/Physical
  • CI - Communication and Interaction
/ Code:
Please give a clear, detailedoutline of child’s difficulties
Please describe what is already being done to support the child. This could include: liaison with other professionals; referrals made; reports received etc. Please include a copy of child’s current individual targets.
What additional support is being provided in the setting? What difference is it making? How much does it cost?
Other professionals / Name / Other professionals / Name
Paediatrician / Portage
Speech and Language Therapist / Social Worker
Health Visitor / Advisory teacher (hearing or visual impairment)
Child Development Centre / Other (please specify)

Please complete the following summary of the child’s progress in the Prime Areas. If possible include the current and previous summaries (e.g. showing progress over approximately 6 month period)

Personal, Social and Emotional Development / Communication and Language / Physical development
Date / Making relationships / Self confidence and self awareness / Managing feelings and behaviour / Listening and attention / Understanding / Speaking / Moving and handling / Health and self care
Referral form filled in by: (please print name)
Position:
Signed: / Date:
Email address for receipt:
SECTION FOR PARENTS/CARERS TO FILL IN
Data Protection Act As part of the support we will provide, we will need to collect, create and securely store electronically, information about your child. The information may be accessed by members of the Additional Needs team or shared with health professionals for the purpose of providing the support service.
The information collected may also be used for the wider purpose of providing statistical data used to assist with monitoring provision and/or determining areas of need in order to target future resources. Data used for this purpose will be anonymous.
I give permission for an Early Years Improvement Advisor to observe my child. YES/NO
I give permission for her to contact other professionals to discuss my child. YES/NO
I give permission for her to receive copies of any reports written about my child. YES/NO
When your child starts school, are you happy for her to liaise with your child’s class teacher if necessary and pass on copies of reports to school? YES/NO
Parent signature:
Please print name: Date:

PLEASE RETURN THE COMPLETED FORM TO:

SUE SHARP, IMPROVEMENT ADVISOR (EARLY YEARS), LEARNING AND ACHIEVEMENT SERVICE, HEREFORDSHIRE COUNCIL

PLOUGH LANE, PO BOX 4, HEREFORD, HR4 0LE

Or email to PLEASE NOTE: IF YOU CHOOSE THIS OPTION THE FORM MUST BE PASSWORD PROTECTED

The information on this form will be considered by the Early Years Improvement Advisors (qualified specialist teachers) and discussed with professionals from the following teams if appropriate - Educational Psychology Service;Child Development Centre (including Paediatricians); Portage Service; Hearing and Visual Impairment Teams; Speech and Language Therapy Service; Children’s Centres