Requestforinvolvement

PATSS(PlymouthAdvisoryTeamforSensorySupport)

Version 1, August 2014 Notprotectivelymarked

PLYMOUTH CITY COUNCIL

Pleasecompleteasmuchoftheformasyoucan,ensuringthatyouhavethesignedconsentoftheyoungperson’sparent or carertoshareinformation,asthisreferralmaybeconsideredataChildren’sIntegratedDisabilityServiceSENDmeeting.Pleasereturnto:

AdvisoryTeamforSensorySupport,WindsorHouse,Tavistock Road, PlymouthPL6 5UF

Tel:01752668000Text/

Parentandchilddetails

Child'snameClickheretoenter name / DOBDateofbirth
Parent or carernameClickheretoentername / DOBDateofbirth
AddressClickheretoenteraddress
HomephoneClickheretoenterhomephone / MobilephoneClickheretoentermobilephone
EthnicityClickheretoenterethnicity / FirstlanguageClickheretoenterlanguage
HospitalnumberClickheretoenterhospitalno

Referrerdetails

Referrer'snameClickheretoenterreferrer / DesignationClickheretoenterdesignation
PhonenumberClickheretocontactnumber

Schooldetails

SchoolClickheretoenterschool / UPNEnterUPN / YearEnteryear
IsthereaSENDPlan? Yes☐ No☐
HasthisstudentseentheirGPorschoolnurseregardingtheirhearing/vision? Yes☐ No☐

Otherservicesinvolvedwiththisyoungperson

NameClickheretoentername / ContactClickheretoentercontactdetails
NameClickheretoentername / ContactClickheretoentercontactdetails
NameClickheretoentername / ContactClickheretoentercontactdetails
NameClickheretoentername / ContactClickheretoentercontactdetails

Summaryofneeds

Clickheretoentersummaryofneeds

Outlineactionstakentohelpyoungpersonsofar

Clickheretoenteractionstakentohelpyoungpersonsofar

Outlinethetypeofsupportyouwouldliketoreceive

Please supply as much additional information as possible including relevant reports from other agencies such as psychologist, therapist, paediatrician, audiologist, REI etc

Youngperson’sview

Click here to enter young person's view

Parent orcarer'sview

Clickheretoenterparent orcarer'sview

Referrer’sview

Clickheretoenterreferrer’sview

I understand that information is recorded about me/my child. I have had the opportunity to discuss the implication of this. Please tick one of the following and sign where appropriate.

1. I agree that personal information about me/my child may be shared between this organisation and other relevant organisations / Name
Signature of child/young person
Date

Signature of Parent/Carer

Date


2. I agree that personal information about me/my child may be shared between this organisation and other relevant organisations except:



/ Name
Signature of child/young person
Date

Signature of Parent/Carer

Date

I understand that the limitations may affect the service that is available. We will not pass on any information without consent, unless we are required by law or we have a statutory duty to do so in order to:
1. Protect you, or, 2. Prevent harm to someone else, or, 3. prevent or detect a crime

3. I do not want my personal information being passed to other organisation / Name
Signature of child/young person
Date

Signature of Parent/Carer

Date

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