Child/Young Person Support Request Form

Sept 17 (To be completed by the requesting school/ setting.)

Name and type of school/setting: / Form completed by:
Role:
Contact Tel:
Contact email: / Headteacher:
Name of child young person/CYP:
Gender / M / F / Ethnicity
Date of birth / SEN Status: / SEN Support
Statement/EHCP
Year Group
The main aims of PSENSP are to improve outcomes for CYP with SEND to enable them to remain in mainstream education, to reduce exclusions, increase attendance and improve attainment in Maths and English. Please indicate below which of these areas you believe to be the mainpriority for this CYP.
There is a risk of the placement breaking down / There is a risk of exclusion
There is a risk of chronic absence from school / There is a risk of low attainment in English &/or Maths
Please outline the CYPs strengths and the specific concerns which prompted this request for support.
What changes do you hope that the intervention of PSENSP will bring about?
Medical information / formal diagnosis
Support requested
Please tick against the menu of services / Curriculum access/differentiation / Involvement of other agencies
Please tick and indicate date of last input / Agency / Date
Challenging behaviour/behaviour management / SALT
Induction/transition / EP
Speech, Language and Communication / Early Years Panel
Autistic Spectrum Conditions / Physio
Adaptive technology/ alternative forms of recording / OT
Developing social and emotional skills / Health Visitor/ School Nurse
Anxious/withdrawn behaviour / CAMHS
Positive people handling risk assessments/training / Social Worker
Professional consultation/conversation / MABS
Other (please detail) / Other (please detail)
Early help in place? Yes
No
If yes, Lead Professional information:
Name:
Contact info:

Please complete information requested overleaf.

Is the child/young person accommodated (under Section 20 of the Children’s Act)? / Is the child/young person subject to a care order? / Is the child/young person subject to a child protection or child in need plan?

Profile of needs

(Please use the attached guidance when completing the profile of need.)

Level from SEN Profile of Need (0 to 4)
Physical & Medical
Hearing
Vision
Speech & Language
Emotional Development
Cognitive Ability
Social Development
Dispositions and Attitudes
Specific Learning Difficulties

Parent’s/Carer’s Comments

Please outline your view of your child’s / young person’s strengths and the specific concerns which have prompted this request for support?
What changes do you hope that the intervention of the PSENSP will bring about?
Any additional comments you would like to make in support of this request?

Child’s/Young Person’s Comments

What is going well for you at the moment?
What would you like to change?

Parental consent

The Portsmouth SEN Support Partnership works closely with professionals in Education, Health and Children’s Services. In order that we can provide the most appropriate response to improve outcomes for your child we need to gather and share information with others who are supporting you or you have had previous contact with. Your signature(s) gives consent for us to speak to other agencies named on this form. You can withdraw your consent at any time. If you have any concerns regarding the sharing of personal information about you or your family please discuss this with the person completing the form with you.
I have understood the completed version of this form and agree to request support from the Portsmouth SEN Support Partnership.
Signature of Parent / Carer…………………………… Please print name……………………………….
Signature of Parent/ Carer…………………..……….. Please print name……………………………….
Date…………………………………………………

This form must be signed by the parent(s) before any work with the child can be undertaken by the

Portsmouth SEN Support Partnership.

Support requested by and authorised by (Headteacher/SLT/SENCO) / Signed:
Role:
Date:

Please attach any recent and relevant information such as IEPs, Assessments and Reports.

Please return to:

PSENSP, Mary Rose Academy, Gisors Road, Portsmouth, PO4 8GT

Special Education Needs: Profile of Need

Needs profile 0 / Needs profile 1 / Needs profile 2 / Needs profile 3 / Needs profile 4
Physical
Health /
Medical / No needs in this area; physical development and general health within normal levels. / Shows limited fine and/or gross co-ordination skills.
Independently mobile without the use of aids, etc., but requires assistance for some
routines/self-care skills.
May need support with administration of regular medication in setting. / Needs some help or requires adjustments to be made to
learning environment to support fine and/or gross motor skills. Limited independence.
Needs assistance on stairs, etc.
Not capable of running and jumping. Can sit on their own or require at most limited external support.
Mobile with the use of walking aids.
Needs daily adult support with self-care. / Needs continuous help with fine and/or gross motor skills. Even
with adaptations to the learning
environment limited participation.
Needs access to wheelchair for movement either independent with chair or adult supported. Can sit when supported.
Requires constant adult supervision to ensure health and safety. / Pupil can at best participate with a simple movement in special situations.
Severe limitations in head and trunk control and require
extensive assisted technology and physical assistance.
Hearing / Hearing within normal limits. / Mild hearing loss (e.g.
conductive or unilateral hearing loss)
Can hear clear voice without amplification / Moderate hearing loss, uses post-aural aids, non-verbal cues
for communication / Severe hearing loss needs aids
e.g. radio aids/ sound filed
systems for curriculum access
May use signing as aid to communication / Very limited functional hearing for speech despite aids
Signing indicated as appropriate
/ Signing as first language
Vision / Vision within normal range,
including when corrected by glasses 6/6-6/12 / Mild impairment
Mild bilateral field loss or adapted to monocular vision. Navigates safely
Wears patch 1-2 hours daily
Colour blind / Moderate impairment, partial sight e.g. needs enlarged print, minimum N14
Moderate bilateral field loss.
Has safe navigable vision in familiar areas. / Severe impairment, partial sight,
e.g. needs access to enlarged
print N18+, most work modified
Has limited navigable vision / Minimal or no sight (e.g. Braille) to access the curriculum.
Needs adult support for safe navigation.
Speech and
Language
(green columns relate to
school age pupils) / Mild language delay / Language & communication skills within
expected range
or mild delay / Moderate / severe delay
in expressive or receptive
language or
Mild language disorder or
mild/moderate speech sound
disorder/delay
of any severity
(without attention/listeni ng difficulties) / Moderate delay in
expressive and / or
receptive
language and or mild
disorder in
speech sound production / Pupil has severe
language delay or
moderate language
disorder Or a
severe speech
sound disorder
(with attention/listeni ng difficulties) / Severe delay in expressive and / or
receptive
language and /
or moderate language /
speech sound disorder / Severe language disorder or diagnosed dyspraxia / Severely limited language skills, uses alternative communication
systems to make needs/choices
known
Needs profile 0 / Needs profile 1 / Needs profile 2 / Needs profile 3 / Needs profile 4
Emotional Development / No significant needs in this area. / Some difficulty forming healthy emotional attachments.
Lacks self-confidence and selfesteem. / Difficulty in forming healthy emotional attachments.
Fairly often shows lack of or inappropriate emotions and interaction with others. / Difficulty in regulating emotions
(e.g. laughing at others distress)
Shows extreme responses in when experiencing changes in routine/transition.
Displays bizarre
ritualistic/obsessive repetitive or stereotyped behaviours / Difficulty in regulating emotions
(e.g. laughing at others distress) including self-harming and selfstimulation.
Behaviour severely withdrawn, bizarre, obsessional.
Cognitive
Ability (green columns relate to
school age pupils) / Cognitive abilities
above or
within broad average
levels or with
a mild delay.
Working above, within or slightly
below the age
expectations of EYFS. / Cognitive abilities above
or within broad
average levels.
Quotient scores on standardised
assessments
85+ / Some learning difficulties,
shows some
difficulties with conceptual
understanding,
(e.g. colours, shapes),
symbolic,
imaginative & make believe play.
Some
evidence of
child working below age
appropriate
achievement within EYFS. / Cognitive assessment
below the 15th centile or a
standardised
score of 75 - 80 / Moderate learning
difficulties in
acquiring basic conceptual
understanding
(e.g. colours, shapes),
symbolic,
imaginative and make believe play.
Working below the age
expectations of EYFS. / Mild to moderate learning difficulties.
Cognitive assessment
below the 5th centile or a
standardised
score of 70 - 75 / Moderate to severe learning difficulties,
significant
delay acquiring basic
conceptual
understanding
(e.g. colours, shapes),
symbolic,
imaginative & make believe play.
Rate of learning &
acquiring new skills is slow.
Significantly (½ chronological
age) below age
expectations of
EYFS / Needs are long term.
Cognitive assessment below 2nd
centile or a
standardised
score of 55 to 70 / Severe learning
difficulties and global delay,
affecting selfhelp and ability to
function
independently
.
Unable to access and make any progress
within EYFS without
significant
interventions and adult support. / Needs are severe, long term and complex.
Cognitive assessment below 0.5
centile or a
standardised
score of below
55
Social
Development
(green columns relate to
school age pupils) / No significant needs in this area. / Some difficulties with forming relationships and social
interaction skills, play and imagination skills and
behaviours e.g. shows some inappropriate responses in
social situations and/or some difficulties in playing with peers. / Difficulties with forming
relationships and social
interaction
skills, play and
imagination skills and
behaviours.
Difficulty coping with changes in
routine/environ ment. / Fairly often disrespectful
to staff and or pupils
Fairly often will interrupt and
seek attention
inappropriately
Known to have bullied others in last 6 months / Significant difficulties with forming
relationships and social
interaction
skills, play and
imagination skills and
behaviours.
Extreme
difficulty coping with changes in routine/environ ment. / Often disrespectful
to staff and or pupils
Often interrupts and seeks
attention
inappropriately
Fairly often disrespectful of property
Feared as a bully, having
physically hurt others / Severe
difficulties with forming
relationships and social
interaction
skills, play and
imagination skills and
behaviours.
Child shows little or no
communicativ e intent. / Shows only minimal
respect for
adults and peers
Very difficult to direct
Often intimidates
and readily resorts to physical aggression
Needs profile 0 / Needs profile 1 / Needs profile 2 / Needs profile 3 / Needs profile 4
Dispositions and Attitudes / No significant needs in this area. / Impulsive behaviour and inconsistency when responding to boundaries and correction. Occasionally disruptive.
Sometimes lacks curiosity and interest in the environment and is unmotivated to explore and learn. / Frequently disruptive.
Behaviour is variable
dependent on context. May
be in conflict with
peers/adults.
Occasionally physically/verb
ally aggressive
Often lacks curiosity and
interest in the
environment and is
unmotivated to explore and learn. / Fairly often distracted from task
Sometimes
inattentive to teacher and
other support
staff
Finds group learning
activities in a variety of
situations difficult / Highly resistant to interventions/a
dult support.
Regularly shows
physical/
verbally
aggressive & intimidating
behaviour to
peers & adults.
Disruptive on daily basis.
Shows little interest in their
surroundings and when
learning new skills. Rarely leads own
exploration and play. / Finds it very difficult to cope with most learning
situations as an individual
or as part of a group
Shows very
little interest in school work at
all / Highly uncooperative and very resistant to interventions and adult support. Behaviour
regularly aggressive on a
frequent and sustained basis to peers and adults.
Shows no interest in their surroundings and when learning new skills. Never leads own exploration and play.
Specific
Learning
Difficulties
(green columns relate to
school age pupils) / Cognitive abilities within broad average levels and above
Reasoning skills fine
No EAL / Some difficulty with subject specific / polysyllabic words
Notable phonic versions of spellings
Reading 2-3 yrs behind CA
May have fine and/or gross motor difficulties
Dyslexia screening test at risk quotient (DST ARQ) 1.0 – 1.4 / Mild learning difficulties
Needs differentiated work and support with conceptual
understanding and reasoning across the core curriculum.
Cognitive assessment below the
5th centile or a standardised score of 70-75 or presents with a very uneven cognitive profile / Very uneven profile of skills
Difficulty in all literacy based subjects
Severe difficulties with HF words
Reading 6-7 years behind CA
Severe fine or gross motor difficulties
DST ARQ 2.0+ / Severe difficulties in accessing any written material.

Profile outline:

Foundation years pupils / School aged pupils
0 / Universal services (support expected from within existing resources) / ‘Quality First Teaching - Universal services’. Support expected from within existing resources
1 / ‘SEN Support - universal services (support expected from within existing resources) / ‘SEN Support or Wave 2/3 intervention. Needs met from within own and delegated resources
2 / ‘SEN Support’ - some additional short-term support for setting to fully assess needs and meet within existing resources longer term / ‘SEN Support' or Wave 2/3 needs met from schools own and delegated resources, with support from outside agencies. Education, Health and Care Assessment may be appropriate.
3 / ‘SEN Support- Additional needs identify longer term support required to ensure child is able to fully access EYFS. Education, Health and Care Assessment may be appropriate. / Education, Health and Care Assessment may be appropriate. Needs likely to be beyond school’s own and delegated resources. Support identified through a Statement / EHCP likely
required for pupil to fully access curriculum in mainstream or special school
4 / Complex needs - may not be able to access EYFS without specialist support. Where the setting is able to demonstrate capacity longer term support required / ‘Statement / EHC Plan’ Complex, long-term needs that would reasonably be met through a statement / EHCP and most likely placement in special school