Additional Information Request (Confidential)

We welcome all children in our setting. Please give us the following information in order for us to plan for any individual needs your child may have.

Child’s Name : D.O.B

Date : Age :

In which borough do you reside ?

Name of any playgroups / nursery previously attended.

Does your child speak any additional language/s ? If so which one/s?

Please tick the following and add any notes you think may be helpful to us.

In which area / areas does your child have additional needs?

□ Speech (e.g. articulation)

□ Language (e.g. using or understanding language )

□ Emotional and/or Behavioural (e.g. playing with other children )

□ Hearing

□ Vision

□ Physical / Movement (eg running, climbing stairs, using hands )

□ Medical condition

□ Other (Please specify)

When were these needs first identified and by whom?

Barnet Early Years Setting SENCO Handbook Does your child have / use or need any specialist equipment or resources ? (e.g. hearing aids, Makaton, signing )

Will your child need support with any of the following ? (Please tick and make notes if necessary)

□ Feeding □ Toiletting / nappies □ Walking □ Medication □ Other (Please specify)

Does your child have any of the following ? (Please tick)

□ Individual Education Plan □ Health Care Plan □ Application for a Statement of Special Educational Need □ Statement of Special Educational Need

Please tick all professionals involved with your child. Please add their name and contact details.

Health Visitor □

Social Worker □

Speech Therapist □

Paediatrician □

Physiotherapist □

Occupational Therapist □

Educational Psychologist □

CAMHS □

Pre-school Education Teacher □

Area SENCO □

Other □

Barnet Early Years Setting SENCO Handbook We have a designated SENCO (Special Needs co-ordinator) at our setting who will routinely liaise with the professionals involved with your child.

The SENCO is ______

We also have access to support and advice from our Area Special Needs Co- ordinator with whom we may discuss your child. You will always be informed beforehand of any contact or discussions held about your child.

Please sign below to indicate that you understand / agree to the above.

Signed______

Date______

Thank you for completing this questionnaire. If you have any concerns or additional information you would like us to be aware of as we plan for your child please let us know in the space below.

Barnet Early Years Setting SENCO Handbook