Early Years Planning and Review Meeting.

Pathway 2 Referral Form.

Name / Date of Birth
Child’s Home Address / Male/Female
Ethnic origin
Home language
Is child/young person Looked After? / Yes / No / If Yes – which Local Authority
Name of Parent(s)/Carer(s) or Person(s) with Parental Responsibility
Home Address
(If different from above) / Relationship
Telephone
Email
Name of any other Parent(s)/Carer(s) or Person(s) with Parental Responsibility
Home Address
(If different from above) / Relationship
Name of pre-school setting/childminder / Address and contact number / Name of contact (keyworker/INCO)
Name of person making referral / Professional title / Contact details / Date and title of supporting report provided.
Summary of child’s needs (please consider the Referral Criteria for Pathway 2 when completing this section):
Name of any other professionals working with child. / Professional title / Contact details / Report included?
Any other relevant information:

Important information for the professional making this referral:

As the person making this referral you are responsible for ensuring the family are clear that this information will be sent to the SEN Assessment Team and considered at the either the EHC Consideration Meeting or the Early Years Planning and Review Meeting. You must ensure they are comfortable with what has been recorded and they are aware that the information may be shared with other relevant professionals. You must seek their consent prior to making this referral and ensure they have reviewed the information you are providing and signed the consent statement below. It is expected that you will complete this referral with the family. Please ensure you provide them with a copy of the relevant ‘parent pack’ and they are clear on the possible outcomes of discussion within the Early Years Planning and Review processes.

Important information for the parent/carer:

This information will be used to consider your child’s needs.

In order to do this we may need to share the details in this referral with other organisations or services.

We are obliged to share information if there are any concerns about the safety and/or wellbeing of a child, young person and/or adult and if there are clear reasons for doing so which are in the best interests of a child, young person and/or adult.

Signatures:

Name and role of professional making this request:
Signature:
Parent/Carer Name:
Signature:
Date form completed and signed:

Freedom of Information and Data Protection:

Your details will be used in accordance with the Freedom of Information Act (FOIA) 2000 and the Data Protection Act (DPA) 1998 or other appropriate legislation, and will be stored electronically. If information you have provided is personal, as defined under the DPA, we will only use it for the purpose for which you provided it. We only share your personal data with a third party if we are required to do so by law or if we need to in order to provide the service you have requested.

(Please read the statement below and sign as indicated.)

  • I am in agreement with the referral for consideration as part of the West Sussex Early Years Planning and Review Meeting.
  • I agree to West Sussex County Council seeking any relevant information from other professionals to help them in deciding how best to support my child.
  • I understand further assessment may be an outcome for some children considered within this process and agree for this to proceed if appropriate.

Signed : ………………………………………………………………………………………………………….

Date : ……………………………………………………………………………………………………………

Once completed please send this form and any other relevant paperwork to:

EYPARM, SENAT, Room 001, County Hall, Chichester, West Sussex, PO19 1RF.