Trafford Council

EHC Needs Assessment Application Form

Section 1a: Tell us who is completing this form and why?

parental request / Early Years setting request / Other (please state)
Title: / Forename(s): / Surname:
Relationship to CYP / Role if applicable
Date: / Contact Details (email)
Telephone: / Signature:
Names of any support helping you to complete this form

Section 1b; Details about the child or young person who this application is for

Forename(s): / Surname:
Known as: / Gender: / Date of Birth:
Address: / School Year:
Ethnicity: / Religion:
School/College/other setting:
Address: / Email:
Named GP: / Surgery: / Address: / Tel No:
Pupil Premium/FSM? / Cared For: / Legal Status: / Social Care Professional Name:
  1. Parent/Carer details (with parental responsibility) Relationship to Child:

Title: / Forename(s): / Surname:
Home Tel: / Mob Tel:
Address: / Email:
  1. Parent/Carer details (with parental responsibility) Relationship to Child:

Title: / Forename(s): / Surname:
Home Tel: / Mob Tel:
Address: / Email:
Add the names and details of other parents/carers if required

Section 2a – My story.

Use this space to record the child’s views. These may be scribed or recorded however best fits the child or young person

Current photo or drawing of child/young person (optional) / What people like about me. What I can do well.
What’s important to me now
What’s important to me in the future
How best to support me
Need to know information about me

Section 2b: Parent Carer Comments

Use this space to tell us your views about the child or young person

Background and historical information
What is working well now? – at home and at school
What is not working now? At home and at school
What is important now?
What is important in the future?
Other important information to know about our family

Section 2c: People who are important to the child or young person

Name / Relationship to CYP / Why they are important
Name of professional person involved / Role of involvement / Place of work / Date of last involvement or contact / Report available
tick

Section 2d:Tell us the names of any professionals involved now or in the past and if there is a report available

Special EducationalNeeds

Please be as detailed as possible. This section will form the basis of the carry out a statutory assessment

Section 3a: Background and history of special educational needs.
Summarise the child/young person’s educational history, including any previous early years provision/school/college/other setting(s) attended. If CYP has moved between settings explain why
Section 3b: Description of child/young person’s special educational needs skills.
List all the additional needs which are impacting on the CYP’s development. Include areas of strengths and specific difficulties and how these are impacting on the CYP. For each need include current scores and attainments if available. Include information such as physical development, attitude to learning, social skills/interaction and behaviour.
Section 3c: Actions Taken by Family, Educational Setting or professionals involved
For each need describe above, summarise the actions already taken and the progress made as a result. Show how the Assess Plan Do Review cycle and graduated approach has been implemented through a staged approach and the time scales involved. Detail how QFT strategies and whole school approaches have been used in order to meet the needs. Summarise the packages of support and interventions taken by educational setting to enable the child or young person’s needs to be met and good educational progress to be made. Include details of any professionals or school based skilled staff and how this advice has be used and the impact on the CYP. Discuss actions taken by SENCO
For parent referrals only, submit as much information as possible but we may contact the educational setting for further details. Do you consent to us contacting the educational setting Y/N
Section 3d: Medical Needs
Please detail any diagnosis or impending diagnosis that may be linked to the additional needs described in section 3b. Include who gave this diagnosis and when.
Test Used / Date / Raw scores/Test scores / Standard Score / Percentile Rank

Section 4: Standardised Test Results or Developmental Profile

Details of any tests or assessments carried out. Include standardised scores and percentile ranks if available. For Parental Referrals only – we will request this information from the educational setting

Section 5: Evidence and Information for submission

Section 5a Parental requests

Please submit the following if available.List the most recent, relevant additionalinformation,including the latest education, health, social care, test or therapy assessment results, reports and referrals. Only include reports written in the last 12 months in the exception of diagnosis reports

School Nurse Report
Health Care Plan
Physiotherapy
Child & Adolescent Mental Health Service (CAMHS)
Occupational Therapy
Speech Therapy
Continuing Health Care Assessment
Other professional reports, please specify:
Diagnostic Reports

Section 5b Educational Setting Requests

In the majority of cases, a needs assessment request should come from the educational setting. The evidence and information they supply is important to the statutory process. Below is a list of required information that will be sought from the setting before the application is considered. If the educational provider is able to submit the following information, this request should be made by them to Trafford EHC Team

Please note that all requests for an Education, Health and Care Needs assessmentfor children and young people of school age should have been discussed with an Educational Psychologist before this referral is made

2 x cycles of detailed and reviewed APDR
2 x Reviewed Provision Maps matched to needs and outcomes
Attendance record for the last 12 months
Evidence of Educational Psychology involvement within the last 12 months
Relevant reports from other professionals within last 12 months that school is aware have involvement with the child/young person/family
Timetable of a typical week in school showing breakdown of support offered and group size
Education Reviews of SEN Support these may include intervention plans, pupil progress evidence, reports and minutes of meetings with the child/young person and/or family in the last 12 months
Details of health care professionals
Details of social care involvement
Evidence of involvement/consultation with SENAS
PEP for looked After Children
Behaviour Plan, including strategies, cues, triggers etc
Analysis of behaviour logs for the last 6 months, including impact of the behaviour plan – do not send actual daily logs
Health Care plan
Risk Assessment

Please see the criteria on which the EHC needs assessment is considered against. These are available on the Local Offer

Section 6:Consent for sharing information

I agree to this request to Trafford Council to assess the needs of my child.

I understand that information (e.g. reports) about my child will be shared with other professionals who are already involved with my child and with those I have asked to become involved with my child, and any that the Local Authority consider is necessary to enable a satisfactory assessment of my child’s needs to take place.

This will be done in line with Trafford’s Information Sharing Protocols. This will only be information that is relevant and necessary, shared with the people who need that information and when there is a specific need for the information to be shared at that time.

You will seek further consent from me if you want another service, not already involved, to see or work with my child.

I understand that electronic records are kept by TraffordCouncil as a result of this involvement and that these records will be kept securely and destroyed safely, according to the council's policy on data storage.

Under the Data Protection Act 1998, I have the right to request a copy of the information the Council holds about me/my child. For more information I can contact the Compliance & Customer Team at Trafford Town Hall.

Parent/Carers/Young Person

You should know that by signing this form you are agreeing to the gathering and sharing of information as detailed in the Privacy Statement above.

Name of Parent/Carer
Date
Signature
Name of child/young Person
(if applicable)
Date
Signature

Please return this completed form to:

EHC Manager

EHC Assessment Team, 2nd Floor

Trafford Council

Sale Waterside

Sale

Greater Manchester England

M33 7ZF

Alternatively you can email this form and relevant reports to

Educational Providers must complete using liquid logic. We cannot accept school based applications using this paper form