Request for EHC NEEDS ASSESSMENT

The form should be completed in full and supporting documentation attached as indicated. Evidence must be provided that intervention has taken place, and provide details of the effectiveness of this intervention. Incomplete forms may be returned.

This form is structured in the following way:-

  1. Details of Person Completing the Request
  2. Evidence checklist
  3. Details of the Child/Young Person & Educational Setting
  4. Evidence of Intervention
  5. Evidence of Need
  6. Parent/Carer’s Views
  7. Child/Young Person’s Views
  8. Additional Information
  9. Consent for EHCP Assessmentand signatures

An EHC needs assessment is a detailed evaluation of a child or young person's Special Educational Needs (SEN). The majority of children and young people with special educational needs will have their needs met through ‘SEN Support’.

Where a child does not make expected progress despite SEN Support, an EHC needs assessment might be the next step. The Local Authority is responsible for carrying out EHC needs assessments under the Children and Families Act 2014.

Information provided by the setting or school should demonstrate the relevant and purposeful action the school has taken to identify, assess and meet the special educational needs of the child or young person, and the progress the child or young person has made in response to this.

  1. Details of Person Completing the Request

Name: / Role:
Email: / Telephone:
  1. Evidence checklist

Please note that by requesting this you are initiating a legal process. Therefore, it is essential that you provide evidence that the child/young person meets both the needs and process criteria, which can be found in The SEN Graduated Response document on the Staffordshire Learning Net
Please ensure the following documents are attached:- / Tick
2 x reviewed termly plans (or individual targets/teaching programmes for the child/young person) (Section C)
Evidence of strategies used
Reports/records from professionals (relating to section C 1 and D6)
One page profile for the child/young person
Parent views and child/young person’s views
C. Student Details
Name: / Date of Birth: / NCY:
Home Address:
Name of Person/s with Parental Responsibility:
Address if Different from Above:
Parent/Carer Telephone No: / Home Language:
Preferred Method of Communication to Parent/Carer: EMAIL/POST/TELEPHONE
LAC (Please Circle): YES/NO
If LAC, current care status:
Home & Funding Local Authority:
Current Educational setting:
Number on Roll:
Previous Educational Setting attended in last 18 months (with dates):
Is the school in receipt of any additional funding specially for this young person? / YES/NO
  • Amount

  • Period of time

  • Type of funding

Percentage attendance (over the last 12 months):
If attendance is low, please state the reason and how it has been addressed:
Pen portrait including needsand key areas of school life that are challenging:
Please use bullet point format
Evidence that this application meets the Staffordshire Criteria and the Local Offer has been explored: Please visit
D. Evidence of intervention at SEN support - Assess, Plan, Do, Review.
D1. Which support services have been involved in the last 2 years? (please circle)
EPS SENSS(LS) SENSS (BSS) VI HI AOT LST PDSS ILP’s
Other (please specify)______
Please include all relevant reports (reports should be no more than 2 years old)
Report attached / Name / Service / Date
D2. Evidence of how this advice, from within the last two years, has been organised, planned and delivered
Please attach the last tworeviewed Individual Learning Plans (or individual targets/teaching programmes for the pupil), evidencing
  • How advice from support agencies has been implemented in relation to the areas of need and the impact of this
  • How the parent(s)/carer(s) are involved
  • How the child/young person has been involved
  • Outcomes

D3. Inthis section, please include information on how provision for this child/young person has been planned.
Individual Structured Interventions (either in or out of the classroom) specifically for the child/young person
D4. Existing Resources
This provision mapping tool should be used to indicate the cost within the school of existing provision.
Provision Details:
Wave-Dept-
Provision
(provision type i.e. W3-SEN-Dyslexia Support) / Start Date / End Date / No of pupils in group / Frequency of intervention per/wk / Length of Session / Role of Adult and name
(HLTA, TA, Teacher, LM, Volunteer, Agency)
TOTAL HOURS PER WEEK ON A 1:1 BASIS
TOTAL HOURS PER WEEK 0N A SMALL GROUP BASIS
(e.g. 2 to 6 pupils constitutes a small group)
E. Evidence of progress
Please complete E1 or E2
Please complete E3and E4if appropriate
Please complete E5 if the Child/Young Person has significant behavioural, emotional or social needs
Please complete E6 for all children/young people
E1. Early Years Stages of Development (please add the dates when these stages were met, to show progress)
Area / 0 – 11m / 8 – 20m / 16 – 26m / 22 –36m / 30 – 50m / 40 – 60m
Personal, Social and Emotional
Communication + Language
Physical Development
Literacy
Mathematics
Understanding of the world
Expressive arts and design
E2. School assessment levels or equivalent (please use EYFS table above to reflect previous levels if applicable) please provide information about your school’s assessment levels. Please provide information explaining your school’s assessment levels.
2 years ago / 1 year ago / Current
Yr Gp / P/NC Level / Yr Gp / P/NC Level / Yr Gp / Assessment Level
Reading
Writing
Number
Science
E3. Standardised test results
Only include scores (from last 2 years)if they are not evidenced elsewhere in external agency reports.
Skill tested / Test Used / Date tested / C/Age / Standardised score
Reading accuracy
Reading comprehension
Reading fluency
Spelling
Number
Other
C/Age = Chronological Age
E4. Test Results from external agencies such as EP or SALT
Skill tested / Tested by / Date tested / C/Age / Standardised score and centile
E5. If behaviour is a concern for this pupil arising from social, emotional or mental health needs, please provide details of the behaviours causing concern. This should include information on intensity, frequency and duration using at least one of the formats below:
  • Timetable records with frequency tallies
  • Incident reports with dates for serious incidents - it is particularly helpful to use an ABC format (Antecedents, Behaviour and Consequences)
  • Examples and recorded frequency of lower level incidents, again it is helpful to record these using an ABC format (as above)
  • Records of sampling observations e.g. charts
PLUS a brief descriptive summary
You may also choose to include:
  • Copies of risk assessments (when appropriate)
  • A completed behaviour checklist – repeated at intervals to give an indication of progress in the area of social, emotional and behavioural skills
  • The views of the class teaching team with supporting detail (covering the above and the impact on other children/young people)
  • Early Help Assessment

E6. Please provide additional information from other professionals dated within two years. This may include information from Independent Futures, Midlands Psychology, SUSTAIN, health providers, Social Care, CAMHS and others.
Written documents should provide evidence that the criteria for the area of need are met.
Service / Report attached
(tick) / Date of last involvement

F. Parent/carer views about the needs of their son/ daughter

Please attach views- use forms

G. Child/young person’s views about their needs and how these could be met
Please attach views. Use person centred approach to obtain the views.
H. Please use this space to note any additional information that you feel is relevant but that you have not been able to incorporate

I. EHC Needs Assessment request consent

Name of Child/Young Person …………………………………… DOB ………………

Parental Consent

I agree to an EHC Needs assessment being requested and, if agreed, to Staffordshire County Council obtaining necessary reports, including a report from the Health Trust, which may require a medical examination.

Signed………………………………Name …………………………(Parents/Carers)

Date:……………………

School Consent

I confirm this request for a statutory assessment regarding of this child’s special educational needs.

Signed ………………………………Name…………………………….. (Head teacher)

Date:……………………

Young Person’s Consent

I am aged 16 or over and consent to this request for an EHC Needs Assessment and, if agreed, to Staffordshire County Council obtaining necessary reports, including a report from the Health Trust, which may require a medical examination.

Signed ………………………………Name………………………………..

Please send this information to:

SEND EHC Assessment and Planning Team

Single Point of Access

Wedgewood Building

Tipping Street

Stafford

ST16 2DH

Request for support from the Local Authority September2015 **Confidential**1