Educational Psychology Service Parental Consent for Involvement

Educational Psychology Service Parental Consent for Involvement

Educational Psychology Service Administration,

Room 105, 1st Floor, County Hall,

Chichester, PO19 1RG

Educational Psychology Service – Parental Consent for Involvement

Child / Young person’s details
The information on this form will be recorded on a database along with any details relevant to subsequent EP involvement.
These records will be held and used in accordance with the provisions of the Data Protection Acts 1984 and 1998.
Name: Date of Birth: Year Group:
______
Early Years Setting / School /College:______
Child’s current level of SEN support
SEN Support: EHCP or Statement:
(Special Educational Needs) (Education Health and Care Plan)
Professional Involvement: Name Contact Number
Learning and Behaviour Advisory Team
Social Communication Team
Early Help
Other
______
______ / ______
______
______
______
______
Why are you seeking Educational Psychologist involvement?
Please circle as appropriate
School and EP Planning Meeting Consultation Telephone consultation REPSI
EHCNA checklist EHCNA involvement SENAT request
Parent / Carer Details
To be completed by the person / people with parental responsibility for the child / young person
Name : ______Relationship to child: ______
Home address: ______
______
Telephone Number(s): ______(Mobile)______
Email address: ______
Name : ______Relationship to child: ______
Home address: ______
______
Telephone Number(s): ______(Mobile)______
Email address: ______
Consent of Parent / Carers for Educational Psychologist Involvement
The setting has been working with you to identify strategies to meet your child’s needs. As part of this, it may be helpful for the Educational Psychologist to consult with the settingto help your child. This may include discussion, observation, working with your child and talking with staff and other professionals involved. Your child may be withdrawn in order to carry out specific tasks.
Please sign below to give permission for this.
Name(Please print): ______Signature:______
Date: ______
The information on this form will be recorded on a database along with any details relevant to subsequent Educational Psychologist involvement. These records will be held and used in accordance with the provisions of the Data Protection Acts 1984 and 1998.
If there are additional person/s with parental responsibility e.g. social worker please attach further information
Strengths and Needs
Please note below information you feel is essential for the Educational Psychologist to know about your child’s strengths and needs
______
______
______
______
School / setting staff Details
Name: Designation: Date:
______
Signature: E-mail Address:
______

Please return completed form to: Educational Psychology Service Administration, Room 105, 1st Floor, County Hall, Chichester, PO19 1RG

Or email to

WSCC EPS Parental Consent Form 1 (01/2016) VER3 1