Person Making Request (Please Tick One Box)

Form Ref No EHC/01

REQUEST TO CARRY OUT A STATUTORY EDUCATION, HEALTH & CARE (EHC) ASSESSMENT

This request is made in accordance with the Children & Families Act 2014, Section 36.

Person Making Request (Please tick one box)

Educational Setting/ Parent/Carer Young Person 16+ Professional

Child/Young Person’s Details

Full legal name: DoB:

Known as: NHS Number:

Address: Name of Educational Setting/School:

Year Group:

Parent/Carer Details

Name(s) of Person(s) with Parental Responsibility:

Name(s) of Person(s) with whom the child/young person resides:

Relationship:

Contact Details inc Address if different to above e-mail address & telephone number

Insert Lac box

Referrer Details

Role: Contact Details – telephone, e-mail & address

The Child/Young Person’s Story So Far

Please give a brief overview of the child/young person’s story so far – how have they got to be where they are now? Professionals Involved (please print)

Summary of support & advice given to support the child/young Name Role Contact Address Contact Contact E-mail person’s SEN Telephone The Child or Young Person’s Special Educational Needs and/or Disability

Please indicate the difficulties which you consider are acting as barriers to curriculum access and progress.

Communication & Interaction Cognition & Learning

Social, Emotional & Mental Health Sensory &/or Physical Needs Difficulties

Please describe below how these difficulties present on a day-to-day basis for the child/young person.

Assessments

Please specify the results of any assessments or reassessment carried out over time within the educational setting or by outside agencies. NB Please include the date of the assessment(s).

Planning (to be completed by educational setting)

Describe here how you have worked with the child/young person and their parents/carers to plan how their Special Educational Needs can be met. This should include some evidence of personalisation and Person Centred Planning. Current Support (to be completed by educational setting)

Please describe in detail what support has already been put in place to meet the child/young person’s SEN. Identify what resources are currently being used (a costed provision map may be attached).

Outcomes

Please outline below the outcomes you are hoping the child/young person will achieve through the support and provision in an Education, Health & Care Plan.

Future Support

Please describe in detail below what support and provision you believe the child/young person needs to meet the above outcomes please note that support and provision should be specific and quantifiable. Additional Information

Please attach relevant reports and advice from other agencies to support this request and to inform the EHC needs assessment should the assessment be started.

Referrer Signature …………………………………………………. Date …………………………….

I give my Parental Consent for the LA to carry out an EHCP Assessment if this application meets the criteria.

Parent/Guardian/Young Person’s Signature

………………………………………………………………………. Date …………………………….

Please tick this box if you do not want your details to be passed to the EHC Independent Supporter Service who will contact you to explain what free support they can offer

PLEASE DO NOT STAPLE THIS FORM / ENCLOSED DOCUMENTS

Please return this form to:

SEN Assessment Team, Floor 4, Number One Riverside, Smith Street, Rochdale, OL16 1XU

Form to be reviewed: July 2015