SEN Specialist Support EMS V3 Nov 2013
Request for Involvement of an EMS for a Child / Young Person
Academic Year to
[NB if you have a completed Inclusion Passport then you need not complete the ** sections of this form]
School Making the Request:
DfE Number: / Tel:
Key Staff Contact: / E-mail:
Name of EMS: / EMS
DfE Number:
Name of Child/Young Person being referred for outreach support from an EMS: / Name:
Age:
UPN:
Key Stage/Year Group: / Gender:
D.O.B:
Name and contact details of parents/ carers of child/young person being referred for outreach support / Parent/ Carer 1
Name:
Tel:
Mobile:
Address:
Email: / Parent / Carer 2
Name:
Tel:
Mobile:
Address:
Email:
**Name and contact details of any partner /professionals involved in the request e.g. SLT/OT/Social Care / Name:
Role:
Telephone:
Mobile:
Email: / Name:
Role:
Telephone:
Mobile:
Email:
Primary Need (Please select where applicable with an X)
Speech, Language and Communication Needs / Specific Learning Difficulty
Autism / Severe and Complex Learning Difficulties
ETHNICITY
White / British / White / Irish
White / Traveller of Irish Heritage / Gypsy / Roma
Any other White / White and Black Caribbean
White and Black African / White and Asian
Any other mixed background / Indian
Pakistani / Bangladeshi
Any other Asian background / Caribbean
African / Any other Black background
Chinese / Any other ethnic group
Refused / Not yet obtained
Please indicate level of SEN:
School Action Plus / Statement
Commentary by referring School (HT or SENCO)
Identify why this request for support is being made
Documentation to be attached to this request for outreach support from EMS and the following as available. Select where appropriate. Please note a) and b) are essential
a)Individual Provision Map or IEP and
b)Inclusion Passport
c)Annual Review documentation
d)Records of Assessment/support/intervention from other Professionals
e)Record of Assessment and Intervention by MainstreamSchool, if A – D is not available
The school making the request has parental permission to share the child’s records and also has their consent to bring in the EMS.
Referred by (Name of Head Teacher) : Date:
Referred by (Name of other approved Professional) : Date:
Referred by(e.g. Speech & Language Therapist
School making Request for Involvement – send completed form and documentation to EMS
EMS use only :
Forms to be sent to:
or:
EMS Admin, Children and Young People’s Service, County Hall,
Northallerton, North Yorkshire DL7 8AE
Disclaimer:A database has been created from the questions on this form. Please do not amend any of the questions in any way, as this may result in your data not being captured.
SEN Specialist Support EMS v3 Nov 2013