Request for a Statutory Education, Health and Care Assessment

REQUEST FOR A STATUTORY EDUCATION, HEALTH AND CARE ASSESSMENT

Before sending this request please ensures that all parts of the form below are completed and any additional information listed below is included. Please add additional boxes if required.The parent(s)/carer(s) and the Early Years SEND Team/setting should then sign the form.

Please note that by submitting this completed form you are signing to say that you have read and understood the Privacy Statement and agree with how your information will be used. This can be found on final page of this document. You can also read the full Privacy Statement by accessing the following web link on the Local Offer here

1. CHILD’S / YOUNG PERSON’S DETAILS:

First name: / Surname:
Preferred name: / Gender:
Date of birth: / Religion:
Ethnicity: / First language:
Home address: / Parent(s) / Carer(s) first language:
Contact number: / Email address:

1. FAMILY COMPOSITION and significant others:

Please provide details of any people significant to child.

Name / Address / Relationship / Parental responsibility?

1. SUPPORT FOR PARENTS: (Please note anything which may affect parents’ understanding of the assessment process or support they might need.)

1. SOCIAL CARE DETAILS

Statutory/Legal measures in place:
Local authority responsible:
Other plans:

1. HEALTH DETAILS:

GP’s name: / GP’s address:
GP’s telephone number:
NHS Number: / Health Authority:
Disability/Diagnosis/ Known Condition(s):
Diagnosed by:
Current medical treatment / Medication(s) taken and impact of these (care plan required? Etc)
Other medical issues and impact of these (care plan required? Etc):
Health issues that may pose a risk to the child/young person or to others:
Family health history:
(Give details of family history that may have a direct impact on the family’s ability to stay strong)

1. SENSORY IMPAIRMENT INFORMATION

Visual impairment
Hearing impairment

1. EDUCATION DETAILS:

Current setting:
Setting address:
Setting telephone number and email address:
Start date and hours per week
Settings organisation and child's place within it (e.g. Preschool mixed ability; group size; special group etc.)
Actual and possible attendance over the last 18 months.
Comments on relevant welfare/attendance issues which might have affected progress.
Setting report enclosed?

1. Which of these services has been working with the child?

Name of Professional and contact details / Interventions and outcomes, with dates
SEND Early Years Support Service – Portage
SEND Early Years Support Service – Teacher tuition
SEND Early Years Support Service– Area SENCo team
Sensory and physical Support Service
Early Years
CIASS Service (Speech and language/Autism Service) Early Years
Early Support Key worker (CDT)
Children and Families First Support Worker
Children’s Centre Family Support Worker
Educational Psychology Service
Paediatrician
Speech and Language Therapy
Occupational Therapy
Physiotherapy
Child and Adolescent Mental Health Service
(CAMHS)
Dietician
Children’s Community Nurse
Other – Please list below

Please attach as appendices - ideally in chronological order and dated:

•the last two Individual Education Plans and reviews;

•details of the current programme of support if not included within the latest Individual Education Plan;

•any other information that is felt to be relevant, such as copies of any recent reports from external support services, including the EPS.

1. Appendices:

1. WHAT DO PEOPLE NEED TO KNOW ABOUT (NAME):

Who I am: my strengths, interests, passions skills(tip: describe all the positive abilities and qualities of the young person)

1. Details of Child’s Learning and Development stage

Please highlight the primary area(s) of identified need :

Cognition and Learning / Communication and Interaction / Social, Emotional and Mental Health / Physical/Sensory/ Medical
Moderate learning difficulties / Speech & language difficulties / Social difficulties / Physical difficulties
Severe learning difficulties / Autistic Spectrum Disorder / Emotional difficulties / Visual impairment
Profound & multiple learning difficulties / Social communication difficulties / Other SEMH difficulties / Hearing impairment
ADD/ADHD / Medical difficulties

1. Please detail attainment in the following areas:

Please include current attainment achieved in the EYFS Profile, Wellcomm Assessment or The SEND developmental progress tracker.

Information provided must demonstrate the rate of progress i.e. a baseline and the current level.

Communication and Interaction:
Including the Prime areas Communication and Language, and Personal, Social and Emotional Development

• Listening and Attention
• Understanding
• Speaking

• Making relationships

Social, Emotional and Mental Health:
Including the Prime area Personal, Social and Emotional Development

• Self-confidence and self-awareness
• Managing feelings and behaviour

Cognition and Learning:
Including the specific areas Literacy, Mathematics, Understanding the world, and Expressive Arts and Design.

• Reading
• Writing

• Numbers
• Shape, space and measure

• People and communities

• The world
• Technology

• Exploring and using media and materials
• Being imaginative

Physical development: Including the Prime area Physical development

• Moving and handling
• Health and self-care

1. ADDITIONAL SUPPORT NEEDED TO OVERCOME THE BARRIERS TO LEARNING.

What the child needs help with over and above that which would typically be needed for a child of their age
Development, education and learning
Communication and Interaction
Friendships and relationships
Behaviour and emotional needs
Independence and self help
Physical, sensory(HI VI) and health needs
Support for the family

1. WHAT (NAME)’S FAMILY WANT FOR HIM/HER IN THE FUTURE:

(tip:parents aspirations, dreams, hopes)

1. DETAILS OF EXCEPTIONAL CIRCUMSTANCES

Since the LA has to justify exceptional circumstances when it is necessary to depart from the Code of Practice, please give details of why the process has be telescoped; e.g. indicate the difficulties experienced by the pupil following a road traffic accident.

1. REFERRER

Parent submitting the request / Yes/No
Name of person submitting the request
Early Years SEND team or Early Years Setting submitting the request
Signature
Date

1. Summary Privacy Notice

Coventry City Council (CCC) Privacy Notice forthe Statutory Assessment and Review Service

The information you provide helps us to process requests for a statutory assessment for children and young people who have special educational needs and disabilities (SEND). It will be used to ensure we meet our legal duties and responsibilities in relation to children and young people with SEND under the Childrens and Families Act 2014 and The SEND Code of Practice 2014.

As part of this we will gather and share your personal information with organisations who will be able to provide advice and guidance to support the statutory assessment process. This may include; schools, early year’s settings, other Local Authorities, internal departments including Social Care, medical and health agencies and sometime the Department of Education.

More information on how we handle personal information and your rights under the data protection legislation can be found in our full Privacy Notice here.

PARENT/CARER Agreement
I/We give consent for the Early Years setting to request a Statutory Education, Health & Care Assessment for my/our son/daughter.
I/We confirm that I/we have read and understood all of the information included in this request. I/We certify that the information, which I/we have provided, is correct.
I/We have read the Privacy Statement and understand that the information provided in this application will be used to ensure that the council’s records are correct. It will also be shared with other agencies and service providers to ensure that our son/daughter receives an appropriate service.
Signature of parent/carer……………………….. Date…………………….
Signature of parent/carer……………………….. Date…………………….

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