Professionals Information for Requesting an Education, Healthand Care Plan Assessment (School age child or young person):

When completing this form, please attach all relevant evidence to support the application as failure to do so may affect the outcome of the panel’s decision. Should you receive a significant piece of information after submission, please contact the Statutory Assessment Service for advice.

  1. Child’s details

Child’s Surname: ______
First name: ______M/F: ___
Date of birth: ______/ Home address:______
______Postcode: ______
Telephone number: ______
Parental/ Carer responsibility
Mother’s name: ______
Tel no.Home:______Mobile:______
Address if different to above: ______
Father’s name: ______
Tel no.Home: ______Mobile:______
Address if different to above:______/ Child’s ethnicity: ______
Immigration status: ______
Child’s first language: ______
Parent’s first language: ______
Is an interpreter required? Yes/No
Is a translation of written documents required? Yes/ No
Name(s) of other people with parental responsibility: ______
Relationship to child: ______
Telephone/ email number if different to home contact: ______
Looked after child: Yes/No
Local Authority: ______
Social Worker: Name: ______
Contact email andtel: ______
Child Protection or Child in Need Plan in place? Yes/No / Do you have any disabilities that require alternative forms of communication or access arrangements for meetings? ______
______
In order to co-ordinate support if appropriate to proceed with a plan, please state the names of any other children living in the family home who currently have a Statement of Special Educational Need or Education, Health and Care Plan: ______
School: ______
Year group: ______
Unique Pupil Number (UPN): ______
Contact person: Name: ______
Designation/ Role: ______
Is the pupil eligible for Pupil Premium? Yes/ No / GP Name: ______
Medical Practice and address: ______
______
NHS Number: ______
  1. Who already knows the child/ young person and may be working with them?

Please continue on a separate sheet of paper or expand if necessary.

Service / Contact name and phone number/email / Details/ reason for involvement / Date of last involvement
  1. Background (include main reason for requesting the assessment)
  1. School Context

Summary of schools attended in the last 18months with attendance figures:
  1. Description of the child’s current skills

a)Physical development –
b)Approaches and attitudes to learning, self-image, confidence and independence, motivational factors, child’s own view of progress –
c)Speech and communication skills –
d)Educational attainments in literacy, numeracy and other curriculum areas -
e)Cognitive development including reasoning, organisational and problem solving skills -
f)Social skills and interaction –
g)Behaviour –
h)Self-help and independence skills -
i)Medical needs:
Diagnoses –
Under assessment for - / Evidence included and appendix number:

Academic progress and attainment

Previous key stages / Last academic year / Current academic year
Autumn / Spring / Summer / Autumn / Spring / Summer
Reading age
Spelling age
Reading
Writing
Speaking and listening
Maths
Science

Please state if these levels are supported or unsupported. If with support, please explain eg scribe, reader etc.______

CATs: Verbal: Non-verbal:Quantitative: Mean:

  1. Relevant factors

a)At school (incl. attendance figures) –
b)At home and in the community – / Evidence included and appendix number:

7. Summary of Special Educational Needs

Identify and list all of the child’s special educational needs and for each describe the child’s level of functioning. Include:
a)Main areas of strength-
b)Main areas of difficulty- / Evidence included and appendix number:
  1. Outcomes of provision

Suggest the main long-term educational /developmental/medical outcomes for the child referring to each of the needs listed above.
  1. Educational facilities and resources

a)What special educational provision has already been made for the child at school action plus?Please outline support here and give detailed information in the evidence of intervention table below. / Evidence included and appendix number:
Interventionor type of support provided eg in class support / Who provides support? Teacher, TA, HLTA, specialist teacher, SENCo etc / Ratio of support (adult(s): child(ren) / How often?
(mins/ week) / Cost of staffing(annual) / Additional expenditureState what for and cost / Evidence of impact of intervention
b)For each need and outcome above, please consider what provisions might meet the Education needs as identified (you are not being asked to recommend a particular alternative school or type of provision). / Evidence included and appendix number:
  1. Health plan or resources

a)What special provision has already been made for the child? / Evidence included and appendix number:
b)For each need and outcome above, please consider what additional health provisions might meet the Health needs as identified. / Evidence included and appendix number:
  1. Social care plan or resources

a)What social care provision has already been made for the child?
Is a CAF currently in place? If so, please attach.
If a CAF has previously been in place, please give date. / Evidence included and appendix number:
b)For each need and outcome above, please consider what additional care provisions might meet theCare needs as identified. / Evidence included and appendix number:
  1. Pupil Views
  1. Parent/ Carer views

If your child is eligible for an Education, Health and Care plan, you will be allocated a keyworker to support you through the process. Do you have any suggestion for who this may be?
  1. Any other useful information:

Parental consent:
I have read and agreed with the details on this form. I agree to the referral and give consent to the sharing of relevant information between education, health and care professionals.
Signature: ______Print Name: ______
Relationship to child: ______Date: ______
Educational Psychologist:
I confirm that this child or young person is known to me and that I am able to prepare reports within the
given time scale.
Signature: ______Print name:______Date:______
Signature of referrer: ______Print name: ______
Designation: ______Date: ______
Contact address and telephone number:

Please return this form and supporting evidence electronically via Egress, GCSX or other secure email

E Harby Advice and Moderation Partner Bexley EIT Feb 2014