Request for medical information/advice to support the development
of an Education, Health and Care Plan for a child/young adult

CONTEXT

This information is sought in accordance with the Children and Families Act 2014. The Local Authority is seeking advice as part of an Education, Health and Care assessment.In providing information the designated medical officer has a duty to co-ordinate the health response to provide an overarching report, or make sure that where there are reports from other health professionals these are appended to the medical advice.

Young Persons Details:

Full Name: / DOB: / Age:
Address: / Male Female
Parent/Carers Name: / Telephone Numbers:
Address (if different): / 2nd Parent/Carer Details:

Advice Givers Details:

Name: / Name of Health Service:
Job Title: / Contact Details:
Qualifications:
Experience:
Is this child/young person known to your service: / Yes / No
If the child/young person has a medical diagnosis please provide details:
What has your involvement been with the child/young person?

SECTION A: Sources of Information

It is important to state the information that has been gathered to form the basis of the report and in particular to justify your findings. Pleaselist all of thesources of information used in preparing the report:

Date / Author / Brief Description of the Evidence

Details of Contact with the Service(if applicable)

Date / Name of Professional / Setting i.e. home, school / Type of contact i.e. observations, assessments / Report Available (tick)

SECTION B: Relevant Background

The following information should be included in this section:

Rationale for the statutory assessment as you understand and the issues that need considering:
Relevant early medical history of the child/young person:
Relevant early history of the child/young person at school:

Description of the child’s needs as being presented to you

Communication and Interaction
Cognition and Learning
Social, Emotional and Mental Health
Sensory and/or Physical Needs

Are there any additional significant factors – if the answers is yes please attached copies of relevant information/advice

EducationYes NoHome CircumstancesYes No

AttendanceYes NoSocial RelationshipsYes No

Previous Assessments– complete the table below to reflect any previous assessments(where applicable)

Name of Test / Date / Age / Raw Score / Age Equivalent / Percentile / Interpretation
Please detail the services, general strategies and resources currently being used to support the child/young person to meet their educational needs:

SECTION C: Views

Set out the views of the parents, young person and educational setting and how they were gathered.

Child/young Person:
Parent/Carers:
Educational Setting:

SECTION D:FormalAssessment

Having considered the interventions currently in place and the child/youngperson’s medical needsyou should now describe the assessment process that has been used(where applicable). The assessment should take two forms –

Standardised Assessments:

Please provide details on the following:
  • What test has been used and why?
  • Explain the test and what it will tell us
  • Describe the test circumstances/length of test/where undertaken
  • Explain the findings of assessments
  • Explain the implications for learning – where will the child have difficulties
  • If standardised assessments have not been used justify why not?

Name of Test / Date / Age / Raw Score / Age Equivalent / Percentile / Interpretation

Observational assessment:Please provide details on the following(where applicable):

Date of Observation / Context / Details of Observation

SECTION E:Identified Special Educational Needs

Identify and list all of the child/young person’s needs following observations/assessments.For each need describe the child/young person’s level of functioning (that is what the child can and cannot do), rate of progress (current, practical, ideal) and the barriers to greater progress within the current situation:

Communication and Interaction
Cognition and Learning
Social Emotional and Mental Health
Sensory and/or Physical Needs

SECTION F: Recommendations

Please detail any additional services, general strategies/resources that will be required:
How will you/your service be involved in supporting these outcomes?

Will you be referring the child/young person to another service?Yes No

If yes please indicate which service(s):

Occupational Therapy / GP
Speech and Language Therapy / CAMH’s
Physiotherapy / Other (please provide details):

Signed:Date of completion:

Name of advice giver:

Please return this form, together with any reports to:

Date Received: / Response due by:
Case Officer: / Panel Date: