REQUEST FOR INVOLVEMENT - INDIVIDUAL CHILD/YOUNG PERSON (FORM 1)

Please complete all sections

Work Requested By
Title/Designation
Setting/School
Telephone Number
E-mail Address
Local Authority / Shropshire / Other
Type of Work / Core / Non Core (Purchased)
Main contact/link for this work (if different from above)
Discussed with EP / Yes / No / Date
Name of Pupil
Date of Birth / Year Group
Address
Postcode
Gender / Male / Female
Ethnicity (Please use LA categories)
Looked After / Yes / No
Home Language
Name of Parent/Carer:
Parental Responsibility:
(if different from above)
Telephone Number
E-mail Address
Has Early Help support been requested? / Yes* / No

* Please attach a copy of the HAF to this request

SEN Code of Practice: (Tick as appropriate)

N/A / SEN Support / Statement/EHCP*

* Please attach most recent EHCP documentation

Other agencies involved:

Name and Role / Contact Details

Additional information (please tick appropriate boxes and attach documents)

Record of attendance (patterns, % - please attach)
Copy of the Provision Map
Copy of the PEP for CIC

Please complete with full information. The spaces below will expand if completed electronically.

Additional information may be attached to the form as necessary

Reason for request / main issue / concern:

What outcome would you like from the involvement of the Educational Psychology Service?

What is the current position - what has been done so far and to what effect? (e.g. evidence of plan, do review)

What positive elements can be built upon? (Please give as many examples as appropriate).

Other relevant facts / information

Pupil/Student views (these may be recorded separately and attached):

Parents views

Note for Parents

When signing this form you are giving permission for an Educational Psychologist to consult about your child. You will have the opportunity to discuss your child directly with the psychologist. The work of the psychologist may involve, for example, observations in the classroom, discussion with teaching staff, working with your child individually.

Please add any notes you wish in the space above and sign the form to confirm that you are happy for the Educational Psychologist to become involved.

Signed: / Date:
(Parent/Carer with parental responsibility)
Head Teacher Signature: / Date:
EPS FORM 1 / March 2016