Education, Health and Care Needs Assessment Request Form

Education, Health and Care Needs Assessment Request Form

For Education Settings: Early Years Foundation Stage

Guidance

This information is sought in accordance with the Children and Families Act 2014. In the first instance all educational settings are required to use their best endeavours to meet the needs of children and young people identified with Special Educational Needs. In providing information, the educational setting must evidence the following:

• A copy of the child'sadditional support plan provided for them under the SEND Support Stage of the Code of Practice 2015;
• The educational establishments assessment of the child's difficulties;
• The outcomes sought by the educational establishmentfor the child;
• The external professional advice that has been sought, which is pertinent to the request for an assessment. Where possible external agencies should be contacted to provide up to date and accurate reports before you submit the request;
• Details of the support and interventions that have been provided for the child;
• An assessment by the educational establishment of the progress made or lack of progress;
• What additional support the educational establishment feels is required which cannot be provided through its ordinary resources.
• This form is intended to be filled out electronically, if you require a hard copy request form please contact the relevant locality casework team using the details found at the end of this request pack.

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Template version 2.0 - updated07.03.2016

Personal Details

Full Name: / Educational Setting:
Date of Birth: / Age / Gender / Type: / Please Select… /
Child's Address: / Ethnicity / Please Select… /
First Language
Do any of the following apply?
(select from the drop down boxes) / Looked After / TAC / Child Protection / Families Working Together / ESCO / Child in Need / Receives Pupil Premium
Please Select… / Please Select… / Please Select… / Please Select… / Please Select… / Please Select… / Please Select…
Parent/Carer Name: / 2nd Parent/Carer Name:
Relationship: / Relationship:
Parents Address (if different) / Parents Address (if different)
Who has parental responsibility?
Phone Numbers / Phone Numbers
Email Address / Email Address
Preferred Method of Contact / Preferred Method of Contact
Who is making the request? / Name / Position / Title

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Template version 2.0 - updated07.03.2016

SECTION A: Pen Picture

In no more than 250 words please briefly describe the child's life so far. You may wish to complete this box after you have filled out the rest of the form

Please Note: The text box is a fixed size due to the word limit, entering anymore text than can fit in the frame above will result in the text being hidden from view.

SECTION B: Attendance

Current Attendance Record - please provide as much information as possible

Name of Educational Setting / Period (Dates) / Actual Attendance
(No. of Sessions) / Possible Attendance
(No. of Sessions per week) / Percentage Attended

SECTION C.1: Child's Views

You may wish to include alternative evidence of the child's views if they are unable to verbally communicate their opinion. Such evidence could include: drawings, photographs, comments from parents, observations etc

What is important to me?
What I like to do / What am I good at?
How do I communicate?
What do I need help with?
These views were gathered / recorded by:

SECTION C.2: Parents / Legal Guardians Views

Where possible, please ensure that the parents and / or legal guardian's views are sought and recorded in the table below.

You may wish to seek views and then fill out table below electronically, if you do so please ensure that parents / legal guardians have had the opportunity to confirm that what has been written is a true and accurate picture.

Parents / Legal guardians will be given the opportunity to submit additional information once a request has been submitted.

What's working well? / What's not working well?
(Eg, Either in school or out) / What would you like to happen?
(Eg. The support you believe is required and the educational outcomes that you believe are not currently being met)

SECTION D.1: Identified Needs

The identified special educational needs – What do you consider the child's difficulties to be which are acting as barriers to curriculum access and progress. You may wish to complete more than one section.

Please include any details of child's needs and/or any diagnoses made.

Barriers to Learning / What does this look like in theEarly Years provision? / What is the impact on learning?
Communication and Interaction
Cognition and Learning
Social Emotional and Mental Health
Sensory and/or Physical Needs (including health needs that impact on access to learning)

SECTION D.2: Additional Significant Factors

If the answer is yes please attach copies of relevant information/adviceInclude where relevant both past and present circumstances that are relevant to the request.

Health
(Anything else that has not already been described above in Section D.1) / YES/NO
Attendance
(Eg: concerns about attendance, erratic attendance , hospital appointments) / YES/NO
Home Circumstances
(Eg. Where relevant, reference to the fact that the request is for: a child of service personnel; a young carer; a traveller child or is adopted.) / YES/NO
Social Care / Family Support
(Eg. TAC, ESCO, CiN, CP, LAC) / YES/NO
Other:
(Eg Pupil Premium. Please give details of funds spent etc.) / YES/NO

SECTION E: Attainment

Attainment/Ability Assessments/Milestones met.

Early Years Foundation Stage Areas of Learning
Date / Age
Months / Communication & Language* / Physical Development * / Personal, Social & Emotional * / Literacy * / Maths * / Understanding the World * / Expressive Art & Design *
Listening / Understanding / Speaking / Moving & Handling / Health & self care / Self
confidence awareness / Managing feelings/ behaviours / Making relationships / Reading / Writing / Number / Shapes, Space & Measure / People & communities / The World / Technology / Exploring
using media & materials / Being imaginative

*E – Emerging, D – Developing, S – Secure

SECTION F: Observation of Progress

Any progress which cannot be quantified or uses non standardised scoring

Please include such information as improvements in behaviour, confidence, self-help / care etc. You may also wish to include any tools used such as Speech and Language Therapy checklist, Early Communication Monitoring Tool, WellComm screening

Date Assessed / Observation / Progress

SECTION G.1:Assess, Plan, Do, Review

Support provided and Early Years Inclusion Funding – Please provide details of inclusion funding awarded.

Term / Funding / Band

SECTION G.2: Current Support Arrangements

Give details of the targeted support provided for the child. This will be in addition to or different from resources available within QualityFirst Teaching.

Please note: There is a section later on (Section I) in the form which you may wish to fill in when a request is made due to exceptional circumstances as outlined in Paragraph 9.3 of the SEND Code of Practice 2015. Section I should be used in conjunction with this section to provide context to the current support arrangements where there are exceptional circumstances

Desired Outcomes (Eg. Support Plan targets, individual targets) / Outside Agency / Strategies Implemented / Provision Delivered / Frequency, Duration and by Whom / Start
Date – End Date / Actual Outcomes: (Impact made)
Met/Partially Met/Not Met
Total Cost: £

SECTION G.3: Additional Support

Please list any additional support required above and beyond what is already being provided.

Outcomes Sought / Outside Agency / Advice given of extra support recommended / Provision to be delivered / Frequency, Duration and by Whom / Cost of Provision (eg. Hourly Rate or cost of resource) / Notes
Total Cost:£

What are the financial implications for providing the additional support identified?

SECTION HDocumentation to support request

Please list details of attached reports/evidence from appropriate services. Include only reports which are relevant to the current request and the child/ young person's identified needs. You are only required to submit evidence where evidence has already been sought and/or given

Please note the involvement of specialists is essential to help evidence that an informed assess, plan, do, review approach has taken place. Please see Paragraphs 6.58-6.62 of the SEND Code of Practice 2015.

EDUCATION
Service Provided By: (Name & Role) / Date of report/consultation record/document relevant to need. / Name of professional (where relevant) / Brief Description of Involvement
(including a brief description of any evidence attached to the request)
1. Educational Psychology consultation records or reports (where available). This is important to show that the assessment of need, provision to meet need and review of the same has been informed by an Educational Psychologist.
2. Working Together Team Discussion Record (where relevant) - previously known as Social Communication Outreach Service.
To show that the assessment of need, provision to meet need and review of the same has been informed by the Working Together Team
3. Sensory professional report or documentation(eg. Sensory Education & Support Team) for pupils whose HI/VI/MSI is affecting access to the curriculum.
4. Specialist Teachers
Such as the Specialist Teaching Team or other independent provider
5. Early Years Serviceas appropriate where significant need has been identified before statutory school age.
6. Portage Service
7. Other Specialist Services
HEALTH
Service Provided By: (Name & Role) / Date of report/ consultation record/ document relevant to need. / Name of professional (where relevant) / Brief Description of Involvement
(including a brief description of any evidence attached to the request)
1. Speech and Language Therapist report or other evidenced language input (Elklan)where language is regarded to be a significant concern/need. This is important to show that the assessment of need, provision to meet need and review of the same has been informed by the Speech and Language Therapy Service or other relevant language specialist.
2. Occupational Therapistdocumentationwheremotor/physical difficulties are regarded to be a significant concern/need. This will show that the assessment of need, provision to meet need and review of the same has been informed by an Occupational Therapist
3. Physiotherapist documentation where motor/physical difficulties are regarded to be a significant concern/need. This will show that the assessment of need, provision to meet need and review of the same has been informed by a physiotherapist.
4. Paediatrician or other expert health practitioner documentationwhere general health/ medical issues are a significant concern/need and, where relevant a Health Care Plan.
5. CAMHS (Child and Adolescent Mental Health Service)
6. 0 – 19 Team (Previously known as Health Visitors)
7. Other Specialist Services
SOCIAL CARE
Service Provided By: (Name & Role) / Date of report/ consultation record/ document relevant to need. / Name of professional (where relevant) / Brief Description of Involvement
(including a brief description of any evidence attached to the request)
1. Where appropriate and relevant, a summary of social care needs, interventions and recommendations provided by Social Careprofessionals, including those provided in the home and community. This could be a record of involvement by, for example, an ESCO worker or TAC or Social Worker.
2.Multi agency meeting minutes
Please include minutes from multi agency meetings such as TAC, Looked After Child, Child in Need, Child Protection meetings.
Please ensure that you have obtained consent from the person holding parental responsibility before sharing sensitive information
3.Electronic Personal Education Plans
4. Prevent Strategy
5. Other Specialist Services
(such as those relating to counselling / gender issues and identity)

SECTION I: Exceptional Circumstances

If there are any exceptional circumstances as defined in the Code of Practice Paragraph 9.3:

"In a very small minority of cases children or young people may demonstrate such significant difficulties that a school or other provider may consider it impossible or inappropriate to carry out its full chosen assessment procedure. For example, where its concerns may have led to a further diagnostic assessment or examination which shows the child or young person to have severe sensory impairment or other impairment which without immediate specialist intervention beyond the capacity of the school or other provider would lead to increased learning difficulties."

Please describe them below:

SECTION J: Consent to Proceed

Please Note: You may wish to print this page separately in order to get a signature. If you are sending the request in electronically please scan in the signed consent form and send along with the request. This will speed up the processing of the request.

Name of Child:

Date of Birth:

As part of the EHC needs assessment the Local Authority will need to request information relevant to the assessment from our partner agencies. Could you please ensure parents / legal guardians are aware of this requirement and have read the LCC SEND Data Sharing Agreement before submitting the request.

Please indicate using the statements below if parents / legal guardian are happy for the Local Authority to request and share information relevant to the EHC needs assessment.

N.B. Without this consent the assessment process cannot proceed

Please indicate in the boxes below whether you do or do not agree with each statement

I agree for the Local Authority to request and share information with other agencies with regards to the EHC assessment process under the Children & Families Act 2014.
I do not agree for information to be shared with the Local Authority as part of the EHC Needs Assessment process under the Children & Families Act 2014
If an assessment is agreed and an EHC Plan is issued the Local Authority requires your permission to enable the plan to be shared with relevant professionals
I DO agree for the Local Authority to share any EHC Plan or feedback produced as part of the EHC needs assessment to partner agencies who have been involved with the assessment.
I DO NOT agree for the Local Authority to share any EHC Plan or feedback produced as part of the EHC needs assessment to partner agencies who have been involved with the assessment.

Signed ______Date ______

* Parent(s)/ Person(s) Responsible(*Please delete as appropriate)

To be completed by the person submitting this request:

Signature: / Name:
Title: / Date:
Contact Tel Number: / Contact Email Address:

Please return this form, together with any reports to the relevant locality team responsible for your area based on child's home address not the educational setting:

East Lindsey:

Lincoln & West Lindsey:

North Kesteven & South Kesteven:

Boston & South Holland:

A cautionary note:

When submitting information to these locality email addresses, we cannot guarantee the information you provide will be sent to us 'securely'. This depends on the email service you use.

If you have any concerns regarding this matter please contact us on telephone 01522 553332 before emailing, to enable us to communicate via LCC secure mail.

or by post to: SEND Team, Lincolnshire County Council, 9/11 The Avenue, Lincoln, LN1 1PA

Office Use

Date Received: / Response due by:
Officer: / Panel Date:

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Template version 2.0 - updated 07.03.2016