Early Childhood Service

Targeted Setting Support Request Form

Section One - Setting Details
Contact Name / Click here to enter text. / Setting Name / Click here to enter text. /
Ofsted URN / Click here to enter text. / Ofsted Grade / Click here to enter text. /
Setting Address / Click here to enter text. /
Setting Postcode / Click here to enter text. /
Phone Number / Click here to enter text. / Email Address / Click here to enter text. /
Date Requested / Click here to enter a date. /
Section Two – Request Details
1. Please select the area of help you require / Choose an item. /
2. Do you have a Setting Improvement/Action Plan in place? / Yes ☐No ☐
If yes, please answer question 3 / 3. Is the support you require part of this? / Yes ☐No ☐
4. What relevant tools/resources have you utilised from the WSCC website and your conversation with the Family Information Service in relation to your request for support? / Click here to enter text. /
5. What outcomes did you have by using these tools/resources? / Click here to enter text. /
6. Have you previously received support from ECS for a similar issue? / Yes ☐No ☐
If yes, please state when this was and provide a summary of what happened:
Click here to enter text.
7. In relation to question 1, please give specific details of what help you require. / Click here to enter text. /
8. Explain what impact support from ECS will have for your setting. / Click here to enter text. /
9. Does this request relate to an individual child? / Yes ☐No ☐
If yes, please complete section three of this form. If stating no because it relates to multiple children, please provide details in section two, question seven.
Section Three – Child Details
10. Child’s Full Name / Click here to enter text. / 11. Child’s Date of Birth / Click here to enter a date. / 12. Child’s Gender / Male☐
Female☐
13. Child’s start date at setting / Click here to enter a date. / 14. Date which child is due to start school / Click here to enter a date. /
15. Please confirm that the parent/carer has read the ‘Integrated Prevention and Earliest Help PrivacyNotice for Early Years and Childcare Settings’ (2018) / Yes ☐No ☐
16. Is the child in receipt of Disability Living Allowance (DLA?) / Yes ☐No ☐
17. Has the setting been in receipt of Disability Access Fund (DAF) for this child? / Yes ☐No ☐
If yes, please provide details of what the DAF was used for, and how this has impacted on the child:
Click here to enter text.
18. What is the child’s area of identified need? / Click here to enter text. /
19. What progress has the child made? / Click here to enter text. /
20. How do you monitor the child’s progress? / Click here to enter text.
A copy of the child’s progress overview attached ☐
21. What strategies have you implemented (including those suggested by other professionals) and what were the outcomes? / Click here to enter text. /
22. Please list the times of sessions that the child attends and the number of practitioners who are supporting in the setting. / Session Times / Number of Practitioners
Monday / Click here to enter text. / Click here to enter text. /
Tuesday / Click here to enter text. / Click here to enter text. /
Wednesday / Click here to enter text. / Click here to enter text. /
Thursday / Click here to enter text. / Click here to enter text. /
Friday / Click here to enter text. / Click here to enter text. /
23. Are there any other professionals working with this child? / Yes ☐No ☐
If yes, please state their names and select their roles.
Click here to enter text. / Choose an item. / Click here to enter text. / Choose an item.
Click here to enter text. / Choose an item. / Click here to enter text. / Choose an item.
Other (please specify) Click here to enter text.
24. Parent/Carer’s Full Name / Click here to enter text. / 25. Parent/Carer’s Phone Number / Click here to enter a date. /
26. Family Address / Click here to enter text. / 27. Postcode / Click here to enter text. /
28. What are the Parent’s views about the child’s area of need? / Click here to enter text. /

Once completed, please send the form and any other relevant documents by email to: . Once received, we will respond to your request within 20 working days.

Page 1 | Updated May 2018 | This document is available online at