Referral/Assessment Form for The

Joint Service for Disabled Children

Referral/Assessment Form for the Early Intervention Support Service and Cheviots Specialist Disability Service

If you have safeguarding concerns about a child or young person, you should complete the Early Help Assessment, which is available at www.enfield.gov.uk/enfieldlscb/download/downloads/id/704/early_help_form_part_1

This assessment should be completed by a professional, alongside the parent/carer and the child/young person. Once complete, it must be emailed to [email protected]

This assessment will give us a better picture of the child’s needs, whether these can best be met by the Joint Service for Disabled Children, and the level of service or support that the family will be offered. Please complete the assessment, and send it back with any reports or information about the child, that you feel will help with our decision.

Not all children and families will need the same level of short breaks and family support services, and some will need more than others because of the impact of their child’s disability or their individual family circumstances.

For more information, see our Short Breaks Statement and the Breakaway magazine on Enfield’s Local Offer website www.enfield.gov.uk/SEND and our Short Breaks leaflet.

AGE GROUP OF CHILD

Age Service being referred for Tick Sections to be completed

Early Intervention Support Service 0 – 5 Years (Pre-School Support Teaching Team, Early Sections 1 – 8 Support Keyworker Team)

Over 5 Years Short Breaks/Family Support Sections 1 – 14

1 SECTION 1: CHILD/YOUNG PERSON DETAILS

Forename(s) DOB/EDD

Surname(s) Gender

Languages spoken Interpreter Required? Yes No

Primary address Contact number(s)

GP Name/Address NHS Number

Religion Ethnicity

If ‘Yes’, please Disability? Yes No provide details

School/nursery attended If ‘Yes’, please state Is there an EHC which, and include a Plan or Statement of Yes No copy with this SEN? assessment form

If the child is aged 0 – 5 Years, please state your concerns about their development

2 SECTION 2: FAMILY DETAILS

Does the main carer have a Yes No If ‘Yes’, please describe: learning difficulty or disability?

Does the main carer have a Yes No If ‘Yes’, please describe: diagnosed health need?

Housed by other Council Housing Living with other Owner Occupier Private Rental local authority Accommodation Association family members Housing Type (tick one)

If the child or family has any other needs, please tell us about them here. For example, a recent bereavement, a long-term illness within the wider family, or housing issues.

3 SECTION 3: FAMILY COMPOSITION Name Address Email address DOB/ Ethnicity Disability Language(s) Interpreter/ Relationship EDD spoken Signer to child Required? (Y/N)

Please state which, if any, of the above provide care for the child/young person, and details of the type of care they provide:

4 SECTION 4: DETAILS OF THE PERSON COMPLETING THIS FORM WITH THE FAMILY Name Agency Role Telephone Email Date form completed

SECTION 5: AGENCIES CURRENTLY INVOLVED WITH THE FAMILY (please name as necessary) Name Role Organisation Contact Details

SECTION 6: INFORMATION SHARING

Has the parent and/or guardian given consent to share/request additional information from the agencies listed in Section 5? Yes No

If ‘No’, please give reason(s) why

5 SECTION 7: FURTHER INFORMATION Tick one box Sleep only 1. The child sleeps well for their age. 2. There is some disturbance of the parent/s’ or carer/s’ sleep patterns due to the impact of the child’s disability. 3. The family follows specialist advice or a sleep programme, but the parent/s’ or carer/s’ sleep is still disturbed, with them having to attend to the child’s needs for an hour a night for three or more nights per week. Would you like information about how to access sleep programmes? Yes No

Tick one box Effect on brothers and/or sisters under 18 years of age only 1. Siblings have friends to play with and they have social relationships appropriate to their age. 2. Siblings regularly have to help with the care of their disabled brother or sister, and this affects their leisure and social time. 3. Siblings have a significant caring role for their disabled brother or sister, and are young carers* Would you like information about how to access sleep programmes? Yes No *If there is a young carer within the family, please provide their details here, so that we can provide you with information on services for young carers. Name

School Date of Birth

Tick one box Impact on family only 1. The family is able to use support and help from the wider family and/or community. 2. The family has limited support from the wider family and/or community. 3. The family has no support from the wider family and/or community.

Medium/ Benefits Tick High 1. The family receives the Disability Living Allowance (DLA) Care Component. 2. The family receives the DLA Mobility Component. 3. The family has a mobility vehicle 4. A claim for the DLA Care Component has been submitted, but no decision has yet been made. 5. The family does not claim the DLA Care Component. 6. The young person receives the Personal Independence Payment (PIP) Daily Living Component. 7. The young person receives the PIP Mobility Component. 8. A claim for PIP has been submitted, but no decision has yet been made. 9. The young person does not claim PIP. 10. The family receives Carers Allowance.

Would the family like advice about applying for DLA or PIP? Yes No

Would the family like advice about applying for Carers Allowance? Yes No

6 SECTION 8: OUTCOMES

An outcome is the benefit or difference you are hoping to see (if your child has an EHC Plan, the outcomes given here should refer to the social outcomes set out within Section D of the EHC Plan).

What are the outcomes you would like to see for… a) …the child?

b) …the parent/s or carer/s?

c) …the child’s siblings (if any)?

7 SECTION 9: CHILD / YOUNG PERSON’S VIEWS

Please support the child/young person to complete this part of the form

How would you describe yourself? How might others describe you?

8 How I Communicate How I Like To Make Choices

Support I need to help me have fun

9 Things I like to do and places I like to go

10 I Don’t Like

11 SECTION 10: ACTIVITIES AND SERVICES

What activities/clubs does the child or young person currently access?

What specific family support or short breaks would you like to be considered?

Can we contact the family in the future regarding activities and services? Yes No

12 SECTION 11: BEHAVIOUR, COMMUNICATION AND LEARNING

Please tick one box in each row (for row numbers 1-5) that best describes your child’s needs in terms of behaviour, communication and learning, to explain why they need more support than a child of the same age who doesn’t have a disability

Low Support Needs Tick Medium Support Needs Tick High Support Needs Tick Tick Because of their behaviour, needs Because of their behaviour, needs Because of their behaviour, Not applicable to my some adult support with their self- more regular adult support with needs 1:1 adult support at all child. 1 care needs, i.e. eating, drinking, their self-care needs, i.e. eating, times with their self-care needs, dressing, toileting and positioning, drinking, dressing, toileting and i.e. eating, drinking, dressing, for these needs to be safely met. positioning, for these needs to be toileting and positioning, for safely met. these needs to be safely met.

Has a learning disability and may Has a severe learning disability Has a severe learning disability Not applicable to my display distressed behaviour and may display highly distressed and challenging behaviour that child. 2 arising from a lack of behaviour arising from a lack of presents significant risk of understanding and/or anxiety. understanding and/or anxiety. harm to self or others.

Has challenging behaviour which Has challenging behaviour which Has challenging behaviour Not applicable to my requires some involvement and requires regular involvement and which requires intensive child. interaction with multi-disciplinary interaction with multi-disciplinary involvement and interaction with 3 communication and learning communication and learning multi-disciplinary services. services. communication and learning services.

Has a learning disability which Has a severe learning disability Has a severe learning disability Not applicable to my impacts on some aspects of which impacts on all aspects of and a severe communication child. communication and social communication, i.e. restricted and impairment diagnosed by a 4 interaction. rigid behaviours, social Speech and Language communication and social Therapist and they need interaction. augmented communication support.

Has communication/learning Has severe communication/ Has severe and complex Not applicable to my needs that can be met within learning needs that cannot be met communication/learning needs child. universal services with some within universal services without that cannot be met by universal support in relation to self-care, significantly more adult support in services without 1:1 support. 5 mobility and engagement with relation to self-care, mobility and peers. engagement, than other children of a similar age.

13 SECTION 12: PHYSICAL DISABILITY

Please tick one box in each row (for row numbers 1-5) that best describes your child’s physical disability, to explain why they need more support than a child of the same age who doesn’t have a disability

Low Support Needs Tick Medium Support Needs Tick High Support Needs Tick Tick Has a physical disability affecting Has a significant physical Has a complex physical Not applicable to my some or all limbs, as identified by disability affecting some or all disability affecting some or all child. 1 a paediatrician or physiotherapist. limbs, as identified by a limbs, as identified by a paediatrician or physiotherapist. paediatrician or physiotherapist.

Has a physical disability and uses Has a physical disability and uses Has a physical disability and Not applicable to my additional equipment at times to additional equipment regularly to uses additional equipment as child. support standing, walking and support standing, walking and their main means of support, 2 feeding, and moving and handling feeding, and moving and handling i.e. standing, walking and generally. generally. feeding, and moving and handling generally.

Has a physical disability and Has a physical disability and Has a physical disability and Not applicable to my requires some adult intervention requires more regular adult requires 1:1 adult intervention child. for their self-care needs, i.e. intervention for their self-care at all times for their self-care eating, drinking, dressing, toileting needs, i.e. eating, drinking, needs, i.e. eating, drinking, 3 and positioning, for these needs to dressing, toileting and positioning, dressing, toileting and be safely met. for these needs to be safely met. positioning, for these needs to be safely met.

Has a physical disability and Has a physical disability and Has a physical disability and Not applicable to my requires some involvement and requires more regular requires intensive involvement child. 4 interaction with multi-disciplinary involvement and interaction with and intervention with multi- services. multi-disciplinary services. disciplinary services.

Has a physical disability that Has a severe physical disability Has a severe and complex Not applicable to my can be met within universal that cannot be met within physical disability that cannot child. services with some support in universal services without be met by universal services relation to self-care, mobility and significantly more adult support without 1:1 support. 5 engagement with peers. in relation to self-care, mobility and engagement, than other children of a similar age.

14 SECTION 13: HEALTH / MEDICAL NEEDS

Please tick one box in each row (for row numbers 1-3) that best describes your child’s health and medical needs, to explain why they need more support than a child of the same age who doesn’t have a disability

Low Support Needs Tick Medium Support Needs Tick High Support Needs Tick Tick Has controlled healthcare needs Has significant healthcare needs Has complex and chronic Not applicable to my requiring specialist intervention. requiring specialist intervention. healthcare needs requiring child. For example, your child takes For example, your child requires specialist intervention. For 1 regular medication for epilepsy regular medication for epilepsy, example, your child has had a which controls their condition. but their condition remains tracheostomy. unstable.

Has healthcare needs and Has healthcare needs and Has healthcare needs and Not applicable to my requires some involvement and requires regular involvement and requires intensive involvement child. interaction with multi-disciplinary interaction with multi-disciplinary and intervention with multi- 2 services (i.e. is seen by a medical services, which requires changes disciplinary services (i.e. is seen team 3-6 monthly). to their health care plan. by a medical team more often than once per month).

Has healthcare needs that can Has severe healthcare needs Has a diagnosed long-term Not applicable to my be met within universal services that cannot be met within medical condition which child. with some support in relation to universal services without requires additional input to self-care, mobility and significantly more adult support regulate and monitor their engagement with peers. For in relation to self-care, mobility condition, e.g. breathing, 3 example, support required for and engagement, than other feeding or uncontrolled medication administration children of a similar age. epilepsy, and these needs can (including insulin injections and only be met in universal epilepsy rescue medication). services with the addition of a 1:1 support worker.

SECTION 14: OTHER NEEDS If your child has any other needs, including sensory needs (a visual or hearing impairment), please describe here

15 WHAT HAPPENS NEXT?

The professional that has completed this assessment with you and your child, will send it to the Joint Service for Disabled Children. The assessment will then be considered by a Panel. The Panel will agree the level of Short Break and Family Support that is appropriate.

You should expect to receive confirmation of the Panel decision within 15 working days of the Joint Service for Disabled Children receiving your assessment form.