Education, Health and Care assessment application

Please complete ALL sections

Please only include the following (where applicable) with your application:

Information from: / Tick √ / Dated
Completed school advice referral form (below)
Latest medical report to detail diagnosis/ CAMHS report
Latest EP report
Latest speech and language report
Latest OT report
Latest report from advisory teacher for HI
Latest report from advisory teacher for VI
Latest report from Learning Support Service
Latest costed provision map
Copy of the reviewed School Based Plan

A summary of Interventions recommended by Outreach Services should be detailed in your submission

Reason for referral:Request for Education, Health and Care assessment

Name:

«Child_Forename1»«Child_Surname» /
Date of Birth:
«ChildDOB»
Address: /
Telephone Numbers:
Name of parents/carers:
/
Name of person with parental responsibility:
School:
/
Year group:
Chronological age:
/
Home language:
Primary need:
/
Secondary need:
Agencies Involved / Name(s)
Paediatrician
Educational Psychologist
Speech and Language
Occupational Therapy
Physiotherapy
Advisory Teacher for Visual Impairment
Advisory Teacher for Hearing Impairment
Social Services
Other
  1. Background Information(please provide brief details):
  1. Academic Levels(please detail the pupil’s academic levels and the expected academic levels for their age):

Subject / Level 12 months ago / Expected level 12 months ago / Level 6 months ago / Expected level 6 months ago / Current level / Expected current level
English – reading
English – writing
Maths

Reading age: Chronological age at time of test:

Test used:

Please provide FSP score if the request is for a Year 1 pupil:

  1. Summary of Needs

Motor, physical and sensory. If there is reference to diagnosis, please provide supporting evidence e.g. medical letter.
Cognition and learning
Communication and interaction
Social, emotional and mental health
Independence
External factors
  1. Agency Support

Agency / Please indicate √ / Frequency e.g. 1x per month / Most recent date of involvement / Report in evidence
Educational Psychologist
Behaviour Outreach team
Specialist Teacher
Autism Outreach team
Attendance Advisory Practitioner
Advisory Teacher support (PD, VI, HI)
Pre-school Advisory Teacher
Home education teacher
Social & Caring Services
Speech and Language Therapist
Physiotherapist
Occupational Therapist
Child and Adolescent Mental Health Service
Child Development Service
MYT PA Inclusion
Other
Other
  1. Please ensure that a costed provision map for this pupil is attached to this application
  1. School / College Based Plan

Has the school /college found it necessary to implement a
school / college based plan for this pupil? / Yes / No
Date of the school / college based plan:
Has the school / college based plan been in place for at least
4 months? / Yes / No
Has the school / college based plan been reviewed? / Yes / No
Please attached a copy of the school / college based plan
7.Support for Presenting Needs

The SEND team are able to allocate resources to help maintain a child in mainstream school without the need for an EHC Plan. Given this, why do you think this child needs an EHC Plan? Please be specific.

  1. Parental Support

Where there have been parental concerns about the pupil’s support in school, have you referred parents to the parent partnership service – Family Action, for advice?

Signature:

Name: (Block CAPITALS):
Position: / Date: