HAMPSHIRE OUTREACH INTO EARLY YEARS REFERRAL FORM
Section 1 : Please complete ALL areas
Date of requestName of child / Male/Female
Date of birth: / Age at referral: / School entry year
Name of parent/carer / Child’s position in family
Address
Post Code / Home Language
Home telephone number
______
Mobile
______
Email address
Early years provision attended
Address of Provision / Contact telephone number of Provision
Name of Supervisor
Name of SENCO / Name of child’s keyperson / SEN/ ISF funded
Y / N
Days and number of hours attended, please state am or pm for example Mon: 3 hrs am
Mon: am/pm Tues: am/pm Wed: am/pm Thurs: am/pm Fri: am/pm
Reason for referral and any diagnosis (Please give as much information as possible, for example the child’s strengths, areas of developmental delay, behaviour that is causing concern, strategies that have worked well. All Requests MUST include copies of the initial concerns form, any reviewed individual/targeted plans or behaviour plans and any other relevant documented evidence including medical reports).
This request has been discussed with …………………………….…………(Area Inclusion Coordinator)
Parent’s views and concerns
Professionals involved:
GP / Health VisitorHealth visitor / Physio
Paediatrician / O.T.
SAL Therapist / Social Worker
Specialist Teacher Advisor / Other
Section 2: It is recommended that the following section is completed by the setting‘s SENCo together with the child’s keyperson and any other members of staff who have involvement
How do you rate your current level of expertise supporting children with additional needs?
(Please rate 0 to 5, where 0 is no confidence and 5 is extremely confident)
1. How confident do you feel implementing strategies for the identified child?
0 1 2 3 4 5
2. How confident do you feel in assessing this child’s needs?
0 1 2 3 4 5
3. How confident do you feel in identifying appropriate targets for this child?
0 1 2 3 4 5
4. How confident do you feel discussing this child’s needs with their parents /carers?
0 1 2 3 4 5
5. How confident do you feel in including this child into small/whole group times?
0 1 2 3 4 5
6. How confident do you feel in supporting this child with their transitions, within your setting and beyond?
0 1 2 3 4 5
In discussion with your team, Area InCo and the parents/carers, please identify some initial goals that you hope your identified child will achieve
Initial / Targets/Goals / Date set1
2
3
Additional / Targets/Goals / Date set
4
5
6
We agree to adhere to the EYEOS good practice guidelines and the signatory has signed on behalf of this setting
Name / Signed / Position / DateHampshire County Council complies with the Data Protection Act 1998. By registering these details I understand that the information will be held securely on Hampshire County Council’s databases for the purpose of recording the support provided to your child and family. I give consent to share information with children’s centres, professionals and agencies as appropriate.
Signature of parent ……………………………………… Date …………………………..………….
Signature of referrer…………………………………….. Date……………………………………….
Please return the form to ‘The Inclusion Team Leader’ at the address on the link below.
Include any additional information or reports to support this request. If not completed in full this request will be returned which will cause delay. If there are any areas of concern that the outreach worker should be aware of please contact the service to discuss.
http://www3.hants.gov.uk/childrens-services/childcare/useful-contacts/sfyc-local-offices.htm
Revised October 2015
2015-10-23 updated outreach request