Childs Full Name
Preferred Name
Person making this request / Name / Position/Role
Address
Telephone number
Email
Checklist for Referral
Request form – All sections to be completed and signed by Parents / Guardians and referrer / ☐ /
Parental/guardian consent form must be completed / ☐ /
Child’s Details
Childs Name / D.O.B / Gender
Ethnicity / Religion
Address
Contact Number / Mobile
Email
Home Language
Social care Status (If Applicable)
Primary SEN Need (DfE Code) / Other (SEN) Need
Has an Early Help Assessment been completed? / Yes / Date commenced / No
If yes please indicate level
1.Universal ☐
2.Universal Plus ☐
3.Partnership response☐
4.Safeguarding / Name of the Lead professional
Name of Education provision:
Address:
Postcode:
Telephone number:
Email:
Name of SENCO
Name of child’s key person
Date started in the provision
Is the provision in receipt of Disability Living Assistance?
LEA School / Nursery The Child will attend:
Start Date:
Number of hours the young person is attending the provision:
Further details
Name / Service / Date of involvement from - to / Assess-Plan – Do – Review Cycle
Other people/ services currently involved with the Young Person / ☐ /
☐ /
☐ /
☐ /
☐ /
☐ /
☐ /
Other people/ services previously involved with the Young Person
Attendance information
Monday / Tuesday / Wednesday / Thursday / Friday
Start Time
End time
Total number of hours
Referral Information

Please describe the nature of support you feel you require to enable your provision to be more inclusive for the child.

Area of Concern:
Observations:
Please attach a minimum of 2 detailed observations specific to your area of concern (observations could include narrative, tracking, event sample etc.)
These observations should be taken at different times and in different contexts.
Please ensure you state:
Date, time, duration, context/situation, details of the activity and aims, adult involvement and child group.
Date of observation 1:
Date of observation 2:
Evaluation of observations:
(Please evaluate all observations submitted)
Following the evaluation of your observations, please provide supporting information:
  • What recommendations have been made?
  • How these have been implemented and over what period of time?
  • What learning outcomes is the child is working towards and progress made towards the outcomes?
  • How planning has been differentiated?
  • Ensure you detail what strategies/resources are being deployed and by whom?

Initial concerns raised by (please name and state capacity e.g. parent, staff member, other agency)
What is working: the impact of effective strategies and interventions on education and wider outcomes
What was not working: reasons why strategies and interventions have been discontinued?
How strategies and interventions are evaluated.
Child’s progress in Early Learning Goals
Please summarise progress when last assessed
Primary Area / Aspect / Date assessed / Child’s age
Year : Month / Dev level
Communication & Language / Listening & attention
Understanding
Speaking
Personal, Social & Emotional / Making relationships
Self-confidence & self-awareness
Managing feelings & behaviour
Physical Development / Moving & handling
Health & self-care
Specific Areas / Literacy
Mathematics
Understanding the world
Expressive arts & design
Authorisation
Authorisation for the Request (setting manager) / Name / Position
Date / Signature
Agreement of Parent(s)/ Carer(s):* / Name(s) / Date
Signature(s)
Date submitted to the Local Authority

Please return to:

Early Support Panel

Early Years

Pre School Inclusion & Portage Team

Floor 3, Civic Office

Waterdale

DONCASTER

DN1 3BUEarly Support Panel

1

A parent or person with parental responsibility must complete and sign the ‘Consent’ section.

Full Name / D.O.B
Ethnicity / Gender
Address
Postcode / Contact Number
Provision / Key Contact
Name of person (s) with parental responsibility
Address if different
Contact Number
Email Address
Is this child / young person “looked after” by the Local Authority?
If Yes: / Local Authority Responsible
Name of Social Worker / Social Worker Contact details
Address
Phone number
Agencies/Services involved / Contact Name / I do/I do not consent to information being shared with Agencies/Services
General Development Assessment (GDA)
Autism Assessment Pathway (ASAP)
Service for children with Hearing Impairment
Service for children with visual impairment
SAID SEND Service
ASCETS
G.P.
Family Hubs
Speech & Language
Physiotherapy
Occupational Therapy
Social Care
Educational Psychology Service
Health visitor
Special Education Needs Team
Other
Has an Early Help Assessment been completed for this young person? / Yes / No
If Yes: Date Early Help Assessment was completed
Name of Lead professional
Position
Contact Details
Parental consent:
I give permission for the Pre School Inclusion and Doncaster Portage Team service to seek information from other professionals who may have relevant information about my child and to store, process and share information with appropriate professionals in compliance with Data Protection laws. I also give permission for members of Pre School Inclusion Team/Doncaster Portage service to work with my child, individually or in a group and that I have the right to be present at any individual session if I wish. I understand that I can withdraw part or all of this consent by writing to the Pre School Inclusion Team/Doncaster Portage service at any time.
Confirmation of Involvement
Doncaster Metropolitan Borough Council is committed to working with Early Years providers to improve outcomes for children in Doncaster. Working in partnership with parents/carers and other professionals, we want to ensure that children in Doncaster have the very best start to life.
Doncaster Metropolitan Borough Council is registered as a data controller under the Data Protection Act as we collect and process personal information about you.
We will process your information for the purposes of offering support from the Early Years Inclusion Team and to monitor and improve the council’s performance in responding to your request. We will also process your information to allow us to be able to communicate and provide services and benefits appropriate to your needs and to ensure that we meet our legal obligations.
We will not disclose any information that you provide ‘in confidence’ to us, to anyone else without your permission, except in the few situations where disclosure is required by law, or where we have good reason to believe that failing to share the information would put someone else at risk. We may disclose information to other partners where it is necessary, either to comply with a legal obligation, or where permitted under the Data Protection Act and the upcoming General Data Protection Regulation (GDPR) e.g., where the disclosure is necessary for the purposes of the prevention and/or detection of crime. At no time will your information be passed to organisations external to the Doncaster Metropolitan Borough Council for marketing or sales purposes or for any commercial use without your prior express consent.
If you have any questions about the collection of your information, what rights you have or wish to complain about the use of your information, please contact Nikki Minnikin, Data Sharing and Protection Officer – or Civic Office, Waterdale, Doncaster, DN1 3BU.
Name of person signing
Relationship to young person
Signature
Date Signed

Early Years Panel

Pre School Inclusion & Portage Team

Floor 3, Civic Office

Waterdale

DONCASTER

DN1 3BU

Email –

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