Early Years and Childcare referral form

For SEN services to individual children and their families

A referral to the Early Years and Childcare service will lead to the family being contacted and their needs discussed. As a result of this a service may be offered which could include:

  • Support to access universal services e.g. children’s centre services and an early education place with a registered provider.
  • Support to access targeted services e.g. an invitation to join a Little Stars group (A Portage approach based in a Children’s Centre).
  • A home based early education service (Portage).
  • Educational advice.

Childs Name: / Child’s home address
D.O.B:
Age:
Parent/carer(s) names / Contact number
Setting/School child attends: (if applicable)
Attendance / Mon Tues Weds Thurs Fri Sat Sun
Referrer
(Name, Job title and contact details)
Other agencies involved? (Eg. Health Visitor, Paediatrician, SALT, Social Care, 1st Base, Physio, OT, CDC, Children’s Centre). / SEN information / Code of Practice Stage:
(Please indicate)
Please indicate contact names for involved agencies: / Early Years/School Action
Early Years/School Action Plus
Undergoing Statutory Assessment
Statement
Is the child a Looked After Child? / Yes No
Has a CAF been completed for this child? / Yes No
Parental permission for EYC involvement (delete as appropriate)
  • I give permission for my child to be referred to the Early Years and Childcare service
  • I understand that if the Early Years and Childcare service becomes involved, information will be shared in accordance with the Data Protection Act and may be shared with other agencies / professionals where appropriate.
Signed: …………………………………………………………… Parent/Guardian
Date:……………………….
Please answer the following questions as this will help us plan our involvement.
This should be shared with parents / carers.
What are your concerns?
What are you already doing regarding your concern?
Please attach current and recently reviewed IEP (where available).
What progress have you noticed?
What are the child’s strengths?
What difference would you like EYC involvement to make?
Is there anything else we should be aware of?
Are there any known risks if home visits will be required?
Signed by referrer:
Date:

Return the completed formby email to:

Orby post to:

Early Years and Childcare Service (F3-B1)

Suffolk County Council

Endeavour House

8 Russell Road

Ipswich

IP1 2BX

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Version 2

2012-10-25