Form FA1 (v8.5)Statutory Assessment Request

Guidance for Islington Early Years settings, Schools and Further Education Colleges

Please complete all sections 1-8of this formand ask the family to complete sections 9-12 (the Family Advice Consent),in sufficient detail to provide a full picture of the childs needs. We will use this information to help us decide whetherto go aheadwith an EHC assessment.If we agree to carry out an EHC assessment this information will also be used to inform the assessment. Requests for assessment will follow the process set out in the flowchart on page 2.

How to use existing documents

If the evidence / information already exists in reports or other documents you are sending us please summarise this and do not repeat the information in full on this request form. We ask that you cut and paste short quotes and refer to the source like this:

‘see page 4, paragraph 3 of the attached SALT report dated 28/06/2016’

Submitting the form

Requests should be emailed securely to

All additional information sent with this form should:

  • be scanned electronically and saved either as word document or a PDF
  • have a file name with the corresponding letterA- Lin the table in section 6 to help us check that the request is complete

Incomplete requests

Requests for assessment cannot be considered until all the necessary documentation has been received. This includes the FA1 form (including signatures), the Educational Psychologist report, evidence of attainment, interventions and child’s progress (usually SEN Support Plans and reviews)and any other documents listed in section 6.

Statutory Assessment Advice

Please make sure the information you send is up to date because if the request is agreed, the information will all be regarded as part of thestatutory advice for an EHC assessment.

Further guidance and help

Guidance notes and prompts are included in red directly in the form.An example of a completed FA1 Form can be found at

EHC Assessment Request Flowchart

1

Form FA1 (v8.5)Statutory Assessment Request

  1. Contact Details

Child
First name
Surname
Address
Date of birth
Gender
Telephone / home
mobile
E mail address
Ethnicity
Home language
Unique Pupil Number
NHS Number
GPs name and address
Parent / carer
First name
Surname
Address
(if different from above)
Telephone / home
mobile
E mail address
Relationship to child
First language
Parent / carer (if a 2nd person has parental responsibility)
First name
Surname
Address
(if different from above)
Telephone / home
mobile
E mail address
Relationship to child
First language
Current educational setting/ school / college
Name
Address
(if different from above)
Telephone
E mail address
Local authority area
Lead professional at the setting/ school
Date the child started
Any previous education setting(s) attended
  1. Reason for asking for a Statutory EHC Assessment

How would a statutory EHC assessment and EHC Plan support the planning and provision to meet the child/young person's special educational needs.
In order for a statutory assessment to be undertaken, the balance of evidence must show that:
  1. The child/young person’s learning difficulties have not responded to relevant and purposeful measures by the school and external specialists over a significant period of time (at least three terms).For very young children in early years settings it may not be possible to comment on progress over 3 terms.
  1. The child/young person’s learning difficulties may call for special education provision which cannot reasonably be provided within the resources normally available to mainstream settings, i.e. the basic pupil funding and the notional SEN funding already in the setting, school or college (at least £6k each year per child)
Please list any evidence attached to this assessment request in section 6.
What future goals or outcomes are you recommending for the next phase of the child or young persons education. (These are likely to be similar for an SEN Support Plan or EHC Plan)
  1. Strengths and Needs

In this section please briefly describe the child/young person's strengths and areas of need including information about any diagnosis or formal assessment.

Special Educational Needs
Overall summary of strengths and difficulties
  • Keep this section brief. 2-3 paragraphs will be enough. Further details should be subdivided under the different headings below (i.e. cognition and learning, communication and interaction)

Cognition and learning
  • Include strengths and needs relating to understanding, participation and engagement and learning style

Communication and interaction
  • Include strengths and needs relating to how they communicate, speech and language, listening and attention skills

Social, emotional and mental health
  • Include strengths and needs relating to social skills,interaction,friendships, emotional development and behaviour

Sensory and / or physical
  • Include strengths and needs related to gross and fine motor skills, sensory processing, personal care, independence and safety

The impact of these difficulties and the implications for learning and development
Please do not prescribe the provision you think is required e.g. ‘he needs a 1:1 TA full time’ as this information will go in the provision section of any plan.
Summarise the impact of the areas of difficulty under the following 4 areas. This section will link directly to the goals and outcomes we will want to achieve.
Learning and work:
  • Her difficulties with attention, concentration and listening skills means that she is easily distracted where there is a lot of noise during lessons.
  • His learning difficulties means that he cannot work at the same level as his peers and is likely to find the secondary curriculum difficult to access.
Community participation and inclusion:
  • Her delayed receptive and expressive language skills meanshe finds it difficult to join in activities with other young people of her own age and means that she doesn’t have any friends at the moment.
  • His misunderstanding of social situations can lead to behavior that often puts himself and others at risk.
Staying healthy (including mental health):
  • His difficulties in understanding and expressing his feelings are a barrier to him establishing supportive relationships with adults and peers and can make it difficult for him to cope in new situations.
  • Her learning difficulties and poor memory means that she is unable to manage her own medication.
Independence and self-help skills:
  • His learning disabilities and poor memory means that he is not able to manage his personal hygiene or take responsibility for money management.
  • His impulsivity and challenging behavior means he is not able to travel independently.
  • Herphysical disabilities mean that she is unlikely to live entirely independently as an adult.

Health Needs
Summary of strengths and difficulties
Which relates to the child / young person’s SEN
This is a summary of the areas of difficulty that relate to the child or young person’s SEN. Health care needs, such as routine dental health needs, are unlikely to be related.
Other Health needs
Other health care needs which are not related to the child or young person’s SEN (e.g. a long term condition which might need management in a special educational setting).
The impact of these difficulties on the child / young person and family
Learning and work
Community participation and inclusion
Staying healthy (including mental health)
Independence and self-help skills:
Social Care Needs
Summary of strengths and difficulties
Which relates to the child / young person’s SEN
A summary of any social care needs which relate to the person’s SEN
Other social care needs
  • Any other social care needs which are not linked to the person’s SEN. This could include reference to any child in need or child protection plan.
Area of need could include: parent/carer strengths & difficulties, info on siblings, the family dynamic, housing/ immigration status, involvements with statutory and voluntary services, work/ training, financial income.
The impact of these difficulties on the child / young person and family
Learning and work
Community participation and inclusion
Staying healthy (including mental health)
Independence and self-help skills:
  1. Progressand Achievement

Please provide details of attendance, attainment and progress over the time.For children in early years settings it may not be possible to comment on attendance or progress over 3 terms.

% / Date range covered
Attendance (over 3 terms)
Early Years Foundation Stage / Current Level / Last terms Level / Previous Level
1. Listening and Attention
2. Understanding
3. Speaking
4. Moving and Handling
5. Health and Self Care
6. Self Confidence and Self Awareness
7. Managing Feelings and Behaviour
8. Making Relationships
9. Reading
10. Writing
11. Numbers
12. Shape, Space and Measures
13. People and Communities
14. The World
15. Technology
16. Exploring and Using
Media and Materials
17. Being Imaginative

School age children

Include assessment information (e.g. age related bands, P levels or similar)that demonstrates current attainment levels and progress over time.

School age children / Current Level / Last Year’s Level / Previous Year’s Level
Numeracy
Reading
Writing
Other curriculum
Details of assessment system(s) used.
Please describe what assessment system you are using e.g. target tracker, PIVATS, IPAT, P scales, other system developed by the school/ college.
Please explain what different grading in the system means.
Details of current goals/ targets
If this information is in the current SEN Support Plan or individual plan please indicate this and attach a copy.
Please list any evidence attached to this assessment request in section 6
  1. CurrentSEN Support

Details of current Special Education provision in place
If this information is in the current SEN Support Plan or individual plan please indicate this and attach a copy.
This should include:
  • The date that SEN Support started
  • Strategies used beyond differentiation which are additional to or different from those normally available
  • Additional resources made available to enable the child to achieve targets
  • Details of parent / carer involvement (e.g. home school agreements, reviews)
(If the individual plan / provision map does not include all of the elements above, separate documentation must be submitted)
The cost of the current Special Education provision in place from the schools budget
The cost of SEN provision needs to be set out in detail and we recommend completing the costings tool found online at or by contacting the
However, if the costings information is in the current SEN Support Plan or individual plan please indicate this and attach a copy.
Please list any evidence attached to this assessment request in section 6
Describe the ‘Assess, Plan, Do, Review’ cycle and how has this been revisited and built upon over time in order to identify, assess and address needs.
If this information is in the current SEN Support Plan or individual plan please indicate this and attach a copy.
Include copies of reports, plans or minutes of review meetings held at various stages over the past year/18 months where appropriate. Please list any evidence attached to this assessment requestin section 6
Please include:
  • evidence of baseline assessment from which progress can be measured
  • Details of parent / carer involvement (e.g.: home school agreements; reviews)

  1. Information and Advice

Please list and provide any supporting documentation by scanning, attaching and returning it with this completed form.To assist with cross checking please reference documents with the corresponding reference number.

Items A and B below are essential. Please note that a request for a statutory Education, Health and Care Assessment cannot be considered until all the documentation listed has been received; any incomplete requests will be returned.

Ref / Document name / Date / No of pages
A / Educational Psychologist Report (essential)
B / Evidence of attainment, interventions and child’s progress -- usually SEN Support Plans and reviews. (essential)
C
D
E
F
G
H
I
J
K
L
  1. People working with this child and family

The Council considers all the information attached to this application and listed in section 6 above. Where we agree that an EHC assessment is required, we will also contact the people listed below for further information.

Please obtain agreement from the people you are listing that they may be included and contacted if needed.

Service and Name of Person / E-mail / Telephone / Details of involvement / Date of most recent involvement
Lead Professional
Class Teacher
Support staff
Educational Psychologist
Speech and Language Therapist
Occupational Therapist
Physiotherapist
Family Support Worker

What multi-agency arrangements have been in place (e.g. CAF, EarlySupport, Child in Need Review). Please provide details of types and dates ofmeetings in the last 12 months.

Type of meeting / Dates

Are any multi-agency meetings planned within the next 3 months? If so please provide details:

Type of meeting / Date /Time / Venue
  1. Signatures

Educational Psychologist

I confirm that I have been consulted about the request for statutory assessment of this pupil’s special educational needs and have provided a written report.

Name
Signature
Date

Head Teacher/Principal

Our school has made every effort to address this pupil’s learning difficulties, which I believe to be of a nature, severity and complexity that meet the Council’s threshold for statutory Education, Health and Care needs assessment. I also understand if this request is agreed the information included will be regarded as statutory assessment advice.

Name
Signature
Date
Checklist for EHC Assessment Requests / Please tick to confirm / For office use only
All sections of the FA1 form are complete in full / ☐ / ☐ /
Any other specialists’ advice that is relevant to the child / young person's learning and development are attached and listed in section 6. / ☐ / ☐ /
A copy of the most recent report from an Educational Psychologist employed or commissioned by the Local Authority is attached and listed in section 6 / ☐ / ☐ /
Other professionals working to support the child and the wider family have been made aware of this request for EHC assessment, and have agreed to be listed in section 7. / ☐ / ☐ /
Section 8 of the FA1 Form is signed by:
the Educational Psychologist and the Head Teacher/Principal / ☐ / ☐ /
Section 12 of the form is signed by the Parent/ Carer (or young person if they are able to make their own request) / ☐ / ☐ /
The information will be sent by secure emailto Special Educational Needs, Pupil Services, 222 Upper Street, London N1 1XR / ☐ / ☐ /

This request will be returned as incomplete if any of the documents listed are not included

or if it is not signed by all relevant parties.

Family Advice and Consent

This appendix to the main form is for families to tell us their story and experiences. There are some prompts below to help you provide this information but you can present it in any way that you like.

  1. About the child/ young person

Child’s history
Child’s interests, likes and dislikes
Child’s strengths and weaknesses
How your child likes to communicate and be involved in making decisions
Child’s own hopes for the future
Parents/carers hopes for the child’s future
How your child can be supported to be heard and understood
Child/young person's support network (Family/friends)
What you feel is currently working well for your child
What you feel is not working for your child
How do you think an Education, Health and Care assessment would help your child?
  1. Other Family Information

The other family information section is not compulsory will help to inform the need for further social care advice as part of anypossible EHC assessment.

What caring responsibilities do you have for anyone else?
Are there any personal health issues, disabilities in the family that make looking after your child more difficult?
Does your child have any need for help with personal care for example bathing, dressing, toileting, which you are not able to meet?
What support is available from family/friends/others?
What leisure time activities have you tried or currently use to enable you as a parent/ carer to get a short break?
Do you have any concerns about your ability to keep the child safe in the home or in the community?

The information provided will be shared with the Islington Short Breaks Service or relevant Social Care Team who will consider any next steps towards any assessment or support for your family.

  1. Feedback on SEN Support

Please tell us your experience related to special educational needs so far by ticking a face and adding a comment.

  1. Have your child’s special educational needs been identified in a timely way?

/ ☐ / / ☐ / / ☐ /
Add comment:
  1. How well do people involve your child in the assessment of their needs?

/ ☐ / / ☐ / / ☐ /
Add comment:
  1. How well do people involve you in the assessment of your child’s needs?

/ ☐ / / ☐ / / ☐ /
Add comment:
  1. Is the information about the additional support being provided by the school for

your child clear?