Bbcdevwebfiles.blob.core.windows.net
September 2018
New request for an Education, Health and Care needs assessment
Please be aware that this form will be used at SEND panel.
1. Details of child / young person
|First Name: | |Family Name(s): | |
|Preferred Name: | |DOB: | |
|Ethnicity: | |Religion: | |
|Name of Current School/College/Setting: | |Date of Admission | |
|Chronological Year Group: | |Actual Year Group: | |
| | |(if different) | |
|Gender: |Male / Female |Child Looked After: |Yes / No |
|(Please highlight) | | | |
| | |Name of Local Authority | |
| | |Looked after Status: |Section 20 / Section 31 / Other |
|Address: | |Postcode: | |
|UPN: | |NHS Number: | |
|First Language: (including | | | |
|British Sign Language) | |Is an interpreter |Yes / No |
| | |required? | |
2. Details of the parents / carers
|Full names of parents / carers: | |
|Relationship to child / young person: | |
|Address: (if different from child/young | |Postcode: | |
|person) | | | |
|First Language: (including British Sign | | | |
|Language) | |Is an interpreter required? |Yes / No |
| | |(Please highlight) | |
|Contact number(s): | |
|Email address: | |
|Full names of anyone else with parental responsibility for the child / young | |
|person: | |
|Relationship to child / young person: | |
|Address: (if different from child / young| |Postcode: | |
|person) | | | |
|First Language: (including British Sign | | |Yes / No |
|Language) | |Is an interpreter required? | |
|Contact number(s): | |
|Email address: | |
|Names of previous schools and dates of | |
|attendance (please provide addresses if | |
|not Bedford Borough): | |
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3. Professional Involvement
Please list current (within 18 months, unless confirming a diagnosis) and relevant professionals as these professionals will be contacted for Advice if an assessment is agreed.
| |Name & Full Contact Details (address, telephone, |Date of Most Recent Involvement|Date of Most Recent Report |
| |email) | |(please include) |
|Advisory Teacher: | | | |
|Speech and Language Therapist: | | | |
|Occupational Therapist: | | | |
|Physiotherapist: | | | |
|Medical Specialist: | | | |
|Educational Psychologist: | | | |
|Social Worker: | | | |
|Early Years Support Team: | | | |
|CAMHS: | | | |
|CHUMS: | | | |
|Early Help: | | | |
|Inclusion Support: | | | |
|Greys: | | | |
|Other: | | | |
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IT IS THE RESPONSIBILITY OF THE CURRENT SETTING/LEAD PROFESSIONAL TO ENSURE ALL REPORTS ARE ATTACHED TO THIS REQUEST BEFORE SUBMISSION TO THE SEND TEAM.
|Details of any medical condition which is relevant to the special educational needs: |
|Medical Diagnosis: |Date diagnosed: |Name of the professional who made the diagnosis: |
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|PRIMARY NEED - Please highlight below: |
|Cognition and Learning |Social, Emotional and Mental Health|Sensory and/or Physical Needs |Communication and Interaction |
|SpLD |MLD |SLD |
|Monday | | |
|Tuesday | | |
|Wednesday | | |
|Thursday | | |
|Friday | | |
SCHOOL TO COMPLETE WITH PARENT or CARER
4. About the child / young person
|Please provide a brief summary / one page profile describing your child. The information you provide will be used in section A of the EHC Plan if the |
|request for assessment is agreed. |
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|Ideas for things to include: |
|Who lives in the family home and who has regular contact with the child / young person? |
|Significant events from the child / young person’s history. |
|Impact of the child / young person’s needs on the immediate and wider family. |
|Names and roles of people who have been particularly supportive. |
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|Each family story is unique and should ONLY include information that parents or carers are willing to share with any professional working with the child /|
|young person. |
|Family Story: |
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|Please list below your short-term hopes, dreams and aspirations for your child; these will be used when requesting Advice from professionals if assessment|
|if agreed and it is very important that they are completed at this early stage. |
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THIS MUST BE COMPLETED BY THE CHILD / YOUNG PERSON (with or without adult support depending on their age and/or needs)
5. About You
|What I like: |What I would like help with: |
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|What I don’t like: | |
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|My hopes, dreams and aspirations: |Names of important people in my life: |
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|If you had support completing this section please tell us who helped you, their name and their role: |
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|Print Name: ________________________________ Role: ______________________________ |
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|Signature: _________________________________ Date: _______________________________ |
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6. Progress and Attainment Data
|Section 1 – Result of reading, spelling or other assessments: |
|Test used: |Date: |Result: |
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|Please indicate the attainment levels as measured in your school that a child of this age would be expected to achieve in the following Year Groups: |
|1 |
|1 |
|Subject |
|Subject: |Result: |
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|Early Years Development Matters – please insert current age band and highlight whether this is emerging, expected or exceeding. |
|Date of assessment: |
|Chronological age at assessment: |
PRIME AREAS (Early Years)
|PERSONAL, SOCIAL AND EMOTIONAL DEVELOPMENT (PSED) |COMMUNICATION AND LANGUAGE (CL) |PHYSICAL DEVELOPMENT (PD) |
|MAKING RELATIONSHIPS (MR) |SELF-CONFIDENCE AND |MANAGING FEELINGS AND BEHAVIOUR (MFB) |LISTENING AND ATTENTION |
| |SELF-AWARENESS | |(LA) |
| |(SC SA) | | |
|READING |
|(R) |
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|Please indicate if the child is currently in receipt of: |
|(please highlight) |
|Additional Needs funding (5 hours per week) |YES / NO |
|Exceptional Needs funding (15 hours per week) |YES / NO |
Date this additional funding was originally agreed:
|Section 4 – Provision made from school’s delegated budget to address the child / young person’s SEN |
|Please attach the following: |X |
|Individual Provision Map | |
|Individual timetable – clearly showing the support given to the young person in each lesson (e.g. 1:1 targeted intervention, small group, 1:1 | |
|in-class etc.) | |
|Please attach any evidence of the impact of targeted interventions – starting points and monitoring of progress. | |
|REMEMBER – schools are responsible for providing, and evidencing, the equivalent of up to 12 hours of weekly support before any additional support should |
|be requested. |
Total hours of support / intervention per week / fortnight as appropriate:
|Type of Support |Number of Hours |
|1:1 | |
|1:1 targeted intervention | |
|1:2 | |
|Small group (max 1:4) | |
|In class general support | |
|Total | |
|Please list the interventions that have been carried out over a reasonable period (18-24 months) and how these have been monitored, evaluated and |
|modified? |
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|Section 5 – Summary of Needs |
|Date identified as needing SEND Support: | |
|Please outline (using bullet points) the child / young person’s special educational needs and difficulties with reference to the relevant sections of the |
|SEND Panel Guidance and any supporting evidence you are submitting. |
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|Strengths are not required at this point and will be requested if assessment is agreed. |
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|Cognition and Learning: |
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|Social, Emotional and Mental Health: |
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|Sensory and / or Physical Needs: |
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|Communication and Interaction: |
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|Self-help and Independence: |
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|Any other relevant information: |
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Information / Documentary Evidence Required
|Evidence Checklist – PLEASE COMPLETE |
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|Along with previous requested attachments, please provide information that is relevant to the Education, Health and Care needs assessment criteria. Much |
|of this evidence should already be available in the child / young person’s SEN Support Plan. Evidence should be based on current need and include |
|information gathered during the previous 18 months. Please ensure documents are dated. |
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|Where essential documentation has been omitted or sections of this form left incomplete, the SEND panel will not be able to consider a request for an |
|Education, Health and Care needs assessment. |
|Please attach all relevant evidence and indicate the evidence included: |X |
|IEPs – 2 reviewed or equivalent SEN Support documents, plus the current one. | |
|Individual Provision Map – indicating how support is being used. | |
|Individual timetable – clearly showing the amount of support given to the young person. | |
|Record of progress – evidence of lack of progress over time despite appropriate interventions. | |
|Attendance record – over last 6-12 months. | |
|Recent unaided written work, dated and annotated – 2 examples of the child / young person’s work (literacy/numeracy work which has been | |
|assessed), including an explanation of the context in which the work was undertaken. | |
|Do not send test papers or standardised assessment paperwork. | |
|All professional reports identified on Page 3 of this application with clear indications of the ways in which their advice has been implemented,| |
|monitored and evaluated. | |
|NB this must include the most recent reports. | |
|SEMH – In the case of requests with regard to Social, Emotional and Mental Health Difficulties, a record which includes an analysis of the | |
|behaviours observed, the strategies used over time and the outcomes. | |
|Early Years – a copy of the child’s Foundation Stage Profile / Early Years Development Matters to date. | |
|Any other information – any other relevant, specific and objective up to date information about the child / young person’s attainments and | |
|social development. | |
All the evidence must combine to demonstrate purposeful and relevant action taken by the school / setting(s) over a sustained period of time.
DETAILS OF THE PROFESSIONAL COMPLETING THIS FORM
Please email the EHCNAF (as a word document) along with any supporting documents to:
sendteam@.uk
|Name: | |
|Contact address and name of | |Postcode: | |
|establishment (if relevant): | | | |
|Job title / relationship to child / | |
|young person: | |
|Contact number(s): | |
|Email address: | |
|Signature: | |Date request | |
| | |submitted: | |
Declaration of parent / carer (this MUST be signed before this request is accepted)
I would like you to consider carrying out an assessment of my child’s special educational needs and I give you permission to contact schools, health services, social care or other professionals and to share my child’s information as necessary.
Signature: ______________________ Print Name: ________________________ Date: _________
Signature: ______________________ Print Name: ________________________ Date: _________
Declaration of young person (if aged 16 or over)
I would like you to consider carrying out an assessment of my special educational needs and I give you permission to contact schools, health services, social care or other professionals and to share my information as necessary.
Signature: __________________________ Print Name: ___________________ Date: ____________
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