Form completed by
Full Name of Person making the request: / Designation:
Date of request: / Date of Admission at current school/ educational placement:(ifany)
Child/Young Person’s Information
Surname: / Forename(s):
Date of Birth: / Gender: / Male Female
Chronological Age: / YrsMths / Home Address:
Home Language: / Postcode:
Ethnicity: / Religion:
School/ educational placement: (ifany) / NC Year Group:

Please give details of person(s) with parental responsibility[1] - the Assessment and Planning Teamwill need to write to them

Parent / Carer Information
Full Name of parent / carer: / Contact Telephone Number:
(including area code)
Mobile number: / Email Address:
Relationship to child: / Home Address:
(if different from above)
Does this person have parental responsibility for the child named above: YesNo
Please tick onebox only
Other parent/ carer:
(if applicable) / Contact Telephone number:
(including area code)
Relationship to child: / Home Address:
(if different from above)
Does this person have parental responsibility for the child named above:YesNo
Please tick onebox only
Communication with the parent(s) / carer(s) will be in English unless specified here (please also note anything else which may affect parent/carers’ understanding of the assessment process):
Social Services details
Is this child Looked After by a Local Authority? / YesPlease provide details below
NoPlease continue to next section
If ‘Yes’, under which section of the Children Act 1989? / Section 20 – Voluntary Care Order
Section 31 – Full Care Order
Section 38 – Interim Care Order
Local Authority that looks after the child:
(if not ESCC please complete details below)
Name of Social Worker:
Contact telephone number:
Email address:
Contact address:
(including postcode)

EHC SA 1 Statutory Assessment Referral Form

Updated: January 2015

1

Evidence to support request for statutory assessment
Please complete this section carefully and ensure that all documentation is submitted. The Authority will not consider incomplete paperwork. Ensure that all information is complete, precise and directly relevant to this request. (Please note that child case files and included information are available to the parent/carer)i.e. School Based Plan and all relevant accompanying documents.
Declaration
I confirm that the statutory assessment procedures have been fully discussed with this child’s parent(s)/carer(s) and that they have had the opportunity to see the attached information supporting this request.
Name: / Signature:
Designation: / Date:

Please return this completed form and supporting evidence by secure email to:

or

via Recorded Delivery to:

Assessment and Planning Team ISEND,East Sussex County Council,

County Hall, Lewes, East Sussex, BN7 1UE

EHC SA 1 Statutory Assessment Referral Form

Updated: January 2015

1

[1]Under the terms of the Children Act 1989, married parents or the unmarried mother of a child automatically have parental responsibility. Other people, including unmarried fathers, step-parents, co-habitees, grandparents and other relations, and foster carers may acquire parental responsibility in a variety of ways, such as being granted a residence order, which confers parental responsibility on them.