Request for Statutory Assessment of Needs

Education, Health and Care Needs Form (Early Years Education)

CONTEXT

This information is required in line with the Children and Families Act 2014. In the first instance all educational settings are required to use their best endeavours to meet the needs of children and young people identified with Special Educational Needs. In providing information, the educational setting must evidence the following:

·  A copy of the child’s SEN support plan; all SEN support plans completed including the most recent/current)

·  An overview of the child’s difficulties;

·  Evidence of the progress made or lack of progress while in the setting. You must include tracking data or summative assessments;

·  A record of the 2 year progress check if applicable.

Child’s Full Name: / Early Years Setting:
Date of Birth: / Private Maintained
Child’s Address:
/ Home Authority:
LAC: Yes No
Parent/Carer Name: / 2nd Parent/Carer Name:
Relationship: / Relationship:
Parent’s Address if different / Parent’s Address if different
Phone Numbers / Phone Numbers

Attendance – please record attendance as Excellent (95 – 100%), Good (85 – 94%), Poor (below 85%)

Date / Name of Educational Setting
Within last 12 months
Previous 12 months

SECTION A

The identified Special educational Needs – What do you consider the child’s difficulties to be which are acting as barriers to learning. You may wish to complete more than one section.

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

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

Health Yes No Social Care or Yes No

Home Circumstances

SECTION B:

Attainment & Progress – Please provide information about the child’s progress using either appendix 1 below, or by attaching the tracking data/summative assessments from your setting. You should also include the 2 year old progress check if applicable.

SECTION C:

Please identify whether you have applied for Enhanced Provision funding from the Local Authority to meet the child’s needs

Enhanced Provision funding £ ______

Current support arrangements: give details of the targeted support the child receives that is additional to and different from normal differentiated activities. If this information is included in your attached SEN Support Plan, you will not need to complete this table.

Identified Outcomes from Targeted Support / How often & how long? / Delivered by / Start
Date / Review
Date / Progress towards Outcomes: (Achieved, Partially Met, Not Met)

Additional support: What additional support do you feel is required over and above that already provided?

Purpose of Support / How often & how long? / Delivered by / Start
Date / Review
Date / Outcomes Sought


Professional Involvement - List details of attached reports/evidence from appropriate services

Professionals Involved / Date of Reports / Date
Assessed / Name and role of Professional
Woodview CDC
Educational & Child Psychology Service
Speech and Language Therapy Service
CAMHS
Medical
Children’s Disability Service
Social Care
Portage
Brookfields Outreach
Chesnut Lodge Outreach
Other (please name)

Please return this form, together with the following (if applicable):

·  Evidence of Child’s voice

·  Evidence of Parent voice

·  SEN Support Plan

·  Tracking Data/Summative Assessments

·  Copies of all professional advice/reports within last 12months

·  Health Care Plan/Risk Assessment if appropriate

The following details are essential:

Document completed by

.…………………………………………………………………….. SENCO/keyperson Date……………….

………………………………………………………………………… Manager Date……………….

Settings should discuss this application and seek agreement from parents or carers before submitting this application.

If you are submitting this electronically, please indicate agreement in the tick boxes below and send in a separate consent form to the authority with the parental signatures.

Parental/main carer’s Consent for Statutory Assessment

I/We would like you to consider my/child’s special educational needs. I/we give you permission to contact my/child’s educational placement, health services, social care or other professionals to obtain information about me/them.

I/We agree that this information can be sent to the Operational Director, Learning and Achievement so that it can be shared with relevant professionals in preparation for the Partnership meeting to determine whether a statutory assessment of needs is appropriate.

If this request for assessment is successful, we give consent for information to be shared with other relevant agencies for assessment purposes.

Parents/young people are advised that there may also be exceptional circumstances where information may be shared with other agencies in line with the Data Protection Act 1998.

Return Completed form to: SEN assessment Team, Rutland House (floor 3), Halton Lea, Runcorn, WA7 2GW

Or send electronically to:

Office Use

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

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Application ofr statutory assessment September 2014

Appendix 1

Please give results from any tracking/summative assessments

Early learning Goals
Date / Age
Months / Communication & Language * / Physical Development * / Personal, Social & Emotional * / Literacy * / Maths * / Understanding the World * / Expressive Art & Design *
Listening / Understanding / Speaking / Moving & Handling / Health & Self care / Self
Confidence awareness / Managing feelings behaviours / Making Relationships / Reading / Writing / Number / Shapes, Space & Measure / People & communities / The World / Technology / Exploring
using media & Materials / Being Imaginative

*Key for completion - 1-Entering 2 – Developing 3 – Secure

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Application ofr statutory assessment September 2014