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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: |

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|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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