20201120 PROFESSIONAL REFERRAL SEN SMMW V4 ... · Web viewWhere the Local Authority receives this form as a request from a health or social care professional we will then write out

Professionals - Request for an Education Health Care (EHC) Needs Assessment This form is to be used by professionals only to request an EHC needs assessment for a child or young person. If you are a parent, carer, young person who would like to make a request, please do not use this form.

This document is to be used by education, health or social care professionals to request an EHC needs assessment. Where the Local Authority receives this form as a request from a health or social care professional we will then write out to the educational establishment that the child or young person attends, to request their information as part of the evidence to consider in deciding whether to undertake an EHC needs assessment.

Please return this form, together with any reports to the SEN Operational Support Team using the Upload Facility on the Local Offer However, if you are having difficulties you can print this form, complete it and e-mail to:- [email protected]

Please note the involvement of other professionals is essential to help evidence that an informed Graduated Response has taken place (SEND CoP 2015 6.58-6.62). If there are no external agencies currently involved with the child or young person a request for an EHC needs assessment may be unsuccessful, as the setting will be unable to evidence that the Graduated Response has been effectively implemented. The SEND Code of Practice says:In considering whether an EHC needs assessment is necessary, the local authority should consider whether there is evidence that despite the early years’ provider, school or post-16 institution having taken relevant and purposeful action to identify, assess and meet the special educational needs of the child or young person, the child or young person has not made expected progress. (9.14)

Submission checklist All relevant assessments/reports/diagnosis

☐ Herringbone (Attendance Record)

☐

Provision Maps ☐ View/Wishes & Family Conversation Form Appendix 1

☐

DP1 consent (signed by parent/s or legal guardian) Appendix 2

☐ Progress data ☐

120210118 PROFESSIONAL REFERRAL V1

mailto:[email protected]

This form is intended to be filled out electronically.

Who is making the request/providing information?

Name: Position / title:

Contact details Telephone number:

Email address:

Child’s full name Child’s address

Date of birth Gender Male ☐ Female ☐Other ☐

Ethnicity Religion

Setting (educational or otherwise) name:

Type of setting

Language child hears at home

Interpreter required?

Yes☐ No ☐

Child/young person’s personal details * Mandatory fields

What are the child’s special educational needs?

Do any of the following apply? Continuing Care Yes ☐ No ☐ Adopted/special

GuardianshipYes ☐ No ☐

Looked after / Care leaver

Yes ☐ No ☐ Section 47 – Child Protection

Yes ☐ No ☐

Section 17 – Child in Need

Yes ☐ No ☐ Early Help Family Support Plan

Yes ☐ No ☐

EYPP – Early Years Pupil Premium

Yes ☐ No ☐ DAF – Disability Access fund

Yes ☐ No ☐

DLA – Disability Living Allowance

Yes ☐ No ☐ Child of an armed service personnel

Yes ☐ No ☐


Special Educational Needs – Education It is expected that the setting will provide additional support from their core funding (Element 2). The nationally prescribed threshold per pupil per year is currently £6,000. (For further information on this please see CoP 9.14 and 9.15, also 5.45 and 6.44)Educational Needs Cycle 1 of graduated

response assess plan do review

Cycle 2 of graduated response assess plan do review

Assess – Please specify assessments/reassessments & results of assessments carried out over time. NB include dates of assessmentsPlanning – Describe here how you have worked with the CYP & family to meet their SEN – please include evidence of person centred planningReview/outcomes – What impact does this have on CYP’s learning generally, for example, classroom practice? Evidence of impact to be included.List itemised costings of provision in place. (mandatory)Future support – Please describe in detail the support & provision you believe the CYP requires to meet their SEN, please ensure this is specific and quantified and costed provision.

Total cost of current provision:


Only complete this section if it is felt your setting CANNOT meet the child / young person’s needs within the resources available to you.

If the identified SEN provision required is additional to and different from those provided for all children, please provide detail below.Education Outcomes Sought for child/young person

Outside Agency

Cost of Provision (if known) (eg Hourly Rate of cost of resource)

Provision to be delivered

Frequency, Duration and by Whom

Advice given of extra support recommended

What are the financial implications for providing the additional support identified?

Total Cost: £__________________________________

In addition, please submit evidence that the additional funding required to deliver the provision above has already been sought from sources already available to the setting (i.e. Early Years, discretionary, School `cluster, Post 16 higher needs funding but has not been made available.


Other agencies / professionals involved with the child. (please tick all that you are aware of). Please be advised that information provided here will help the local authority to identify those agencies / professionals from whom we need to seek information / evidence as part of the EHC needs assessment request; we therefore seek your support to identify relevant agencies.

Education Health Social CareAccess through Technology

☐ Child and Adolescent Mental Health Services.

☐ Children with Disabilities Social Care

☐

Dyslexia Specialist

☐ Children’s Community Nursing

☐ Other Children’s Social Care

☐

Educational Psychology

☐ Occupational Therapy ☐ Early Help Family Support Lead Professional – please specify who and which agency

☐

Portage ☐ Ophthalmology (in hospital eye care)

☐ Wheelchair Services ☐

Sensory Support ☐ Orthotics ☐ Short Breaks Service ☐Armed Service Children’s Education Advisory Service

☐ Paediatrician ☐ Adult social care ☐

Careers adviser / preparation for adulthood (please specify who)

☐ Physiotherapy ☐ Youth Offending Services ☐

Virtual School Children In Care / SEN

☐ Speech and Language ☐ Continuing Care ☐

Other: ☐ 0-19 Healthy child programme (Health visitor/school nurse)

☐ Other: ☐

Other: ☐ Other: ☐ Other: ☐

If you have any reports from any professional which related to the child / young person and are dated within the last 24 months, please send them in with this referral.

Professional Contact Details5


Name: Name:Job title/org:

Job title/org:

Address: Address:

Telephone: Telephone:Email: Email:Report attached

Yes☐ No ☐ Report attached

Yes☐ No ☐

What support is being provided?



Job title/org:

Address: Address:



Yes☐ No ☐




Job title/org:

Address: Address:



Yes☐ No ☐




Special Educational NeedsRank in order if more than one in diagnosis field – 1 being the most significant needPrimary Special Educational Need Yes/No Diagnosis RankingCommunication & Interaction

Yes ☐ No ☐

Social Emotional & Mental Health

Yes ☐ No ☐

Cognition & Learning

Yes ☐ No ☐

Sensory &/or Physical Needs

Yes ☐ No ☐

Additional Needs Yes ☐ No ☐

Year Group The year group CYP is learning in

Actual year group for age of CYP

Attendance

Current attendance record – please provide as much information as possible or attach a herringbone/full attendance record.

Period (Dates) Possible attendance (No of sessions/hours) per week

Actual attendance (No. of Sessions per week)

Percentage Attended


Education – attainment and tracking dataPlease consider the following:

Is the pupil making good progress towards meeting or exceeding the expected attainment for their age (as set out in the school’s own curriculum and assessment policies), including in English and mathematics?

Given their starting points, are they making good progress towards meeting or exceeding the challenging goals set for them?

What benchmarks has the school used to set these challenging goals?

For KS4 pupils: What qualifications will the pupil be entered for, and what are they expected to

achieve in these?

Please also submit last term and last end of year attainment and tracking data or utilise the tables below, rating the attainment in each of the early learning goals in the prime areas of learning. 1 = emerging, 2 = expected, 3 = exceeded

Early Years Foundation Stage Communication & Language Development ELG 01 Listening & Attention ELG 02 UnderstandingELG 03 Speaking

Physical Development ELG 04 Moving & HandlingELG 05 Health & Self Care

Personal, Social & Emotional Development ELG 06 Self-confidence and self-awarenessELG 07 Managing feelings and behaviourELG 08 Making relationships

LiteracyELG 09 Reading ELG 10 Writing

MathematicsELG 11 NumbersELG 12 Shape, space and measures

Understanding of the World ELG 13 People and communities ELG 14 The world ELG 15 Technology

Expressive arts and designELG 16 Exploring and using media and materials ELG 17 Being imaginative


Phonics Screening Check Year 1 Year 2 (if taken)Score / 40Above expected standard (yes / no)

KS 1 Teacher Assessment

Reading Writing Mathematics

Attainment* P Scale (if BLW)

* teacher assessment codes: BLW = Below the pre-key stage, PKF = Pre Key Stage Foundations of the Expected Standard, WTS = Working Towards the Expected Standard, EXS = Expected Standard, GDS = Greater Depth, A = Absent / Not enough information to assess, D = Disapplied from National Curriculum

KS 2 Tests and Teacher Assessment

Reading Test Scaled Score (80 – 120)

Reading Teacher Assess-ment

Writing Teacher Assess-ment

Grammar, Punctuation and Spelling Test Scaled Score

Mathematics Test Scaled Score (80 – 120)

Mathematics Teacher Assess-ment

Attainment* P Scale (if BLW)

* teacher assessment codes: BLW = Below the pre-key stage, PKF = Pre Key Stage Foundations, PKE = Pre Key Stage Early Development, PKG, Pre Key Stage Growing Development, WTS = Working Towards the Expected Standard, EXS = Expected Standard, GDS = Greater Depth, A = Absent / Not enough information to assess, D = Disapplied from National Curriculum

NOTE: If preferred, you may append the child’s attainment record instead of completing Tables 1-5. However, the commentary box (below) for attainment and tracking data must still be completed to support the interpretation of the data you are providing.

Description and commentary of attainment and tracking data. Please provide additional information/commentary relating to the attainment data particularly to help the local authority understand and interpret setting specific assessment data.


Continuation of child/young person details

Parent carer name 2nd parent carer name

Relationship Relationship

Address (if different from child)

Address (if different from child)

Telephone number(s)

Telephone number(s)

Please note unless otherwise specified we will contact you in the first instance via email.Email address Email address



Do any of the following apply to the parent(s) / legal guardian(s)?Requires an interpreter for verbal communication?If yes, please specify which language (i.e. French, Portuguese sign language)

Yes ☐ No ☐ Requires translation for written communication? If yes, please specify which language (i.e. French, Portuguese sign language)

Yes ☐ No ☐

Has other needs of which the LA should be aware? (i.e. learning difficulty or disability, accessibility needs)

Yes ☐ No ☐ A member of the armed forces?

Yes ☐ No ☐

Registered GP surgery details*


If this document is being submitted as a request for an EHC needs assessment, a SEND DP1 form must be attached SIGNED BY THE PARENT/S OR LEGAL GUARDIAN. Please be advised that the request will not be processed without this consent being submitted.Note: If you are completing this form as part of a request for existing information, you do not need to complete the SEND DP1 as this will have been obtained elsewhere in the process.

To be completed by the person submitting this request:

Signature: Name:

Title: Date:

Contact Tel Number:

Contact Email Address:

Please complete appendices 1 & 2


Appendix 1My Views/Family Conversation Form1. Health Details

Disability/Diagnosis/ Known Condition(s)

Diagnosed By Medication administered (if

any)

Is this medication

taken during sessions?

Yes ☐ No ☐

Yes ☐ No ☐

Yes ☐ No ☐

Yes ☐ No ☐

Yes ☐ No ☐

Health issues that may pose a risk to the child/young person or to others:

Current medical treatment:

Family health history:(Give details of family history that may have a direct impact on the family)

2. Social Care Details (if known) Statutory/Legal measures in place:Local authority responsible:Other plans:


3. Key ContactsYou do not need to complete if all details completed on the EHC needs assessment referral form please add any that are not on the referral formPlease provide details of any agencies/services that currently have contact with your family, including the nature of involvement. Please bring copies of current reports/assessments from these workers to the meeting.

Which outside agencies are supporting your child?

Virtual Sensory Support Services, Virtual School Children In Care, ASD Team

Educational Psychologist/ EPSS Specialist Learning Support Teacher Child and Adolescent Mental Health Service Speech and Language Therapist Occupational Therapist Physiotherapist Other

What help are these agencies providing for your child?

Service/ Agency

Named contact (address/ tel. no. / email)

What help is provided?

Report provided

Yes ☐ No ☐

Yes ☐ No ☐

Yes ☐ No ☐

Yes ☐ No ☐


4. Family Members/Significant OthersPlease provide details of any people significant to <name>.

Name Relationship

What SUPPORT do you receive from family friends, community members and other professionals? Name Support

offeredRegularity(Weekly, Monthly, Yearly) S

ervi

ces

Arts

&

cultu

re

Edu

catio

n

Phy

sica

l A

ctiv

ity

Fam

ily &

Fr

iend

s

Faith

&

mea

ning

Oth

er

e.g. Grandparents (Names)

E.g. Look after “child/young person” at the weekend

Monthly Y


5.Child/Young Person’s ViewsTell us about your family, education setting and friendshipsWhat do you enjoy? Who with? What are you good at? What are your hobbies or interests? Where do you go to do these things? Do you face any challenges or barriers accessing these activities?

In educational setting:

Outside of educational setting:

What do you find difficult, challenging or stressful? What’s not working well, or what do you need to help you?

Do you feel safe?

In your day to day life, what is going well for you and your family?


What is important to you?

What are your aspirations, goals, wishes, hopes and ambitions?

How do you want to be given information? e.g. talking, signing, pictures, technology

How can we involve you in decision making and make sure that your choices are listened to and understood?


6. Parent/carer viewsWhat is your child / young person good at in the following areas?Speaking, listening and joining in

Knowledge, skills and understanding

Feelings and friendships

Hearing, listening, physical and independent skills

What are your aspirations, goals, wishes, hopes and ambitions for your child?


What would you like your child / young person to be able to do?

In the next 12 months:

In the next 5 years:

What skills do they need to develop to make these things happen?

Who and what would help or support them to achieve this?


Child’s story so farCYP’s history including the views of parents / carers and professionals about CYP’s needs now and in the future. Please keep information current, but include relevant history relating to education, health and care and any other information you feel is relevant. Describe what is happening where and when, how often and for how long, give examples if possible.

Is there anything else that may be influencing the current difficulties and/or is there any other information you wish to share?


Appendix 2SEND Education Health Care Plan Information Sharing and Consent for Parents / Young People (SEND DP1)

Name of child or young person: Date of birth:

Norfolk County Council needs to share information as part of the assessment and planning process for an Education Health and Care Plan (EHCP) and, where an EHCP is made, to share it and supporting information with relevant agencies and professionals.

We need the permission of the right person to do this, who is: the parent or legal guardian where the child is of statutory school age, the young person where the young person is over statutory school age (unless they

lack capacity to do so as defined within the Mental Capacity Act 2005)

If you change your mind you can withdraw your permission.

The local authority has a duty to share information without your consent if it is needed: to find out if a child or adult is at risk of harm or we need to help a child or adult who

is at risk of harm; for the prevention or detection of crime.

In addition, the local authority is also allowed to share the EHCP without consent for the specified purposes. Find out more by reading Chapter 9.211 of the SEND Code of Practice 2015.

The information will be recorded and stored in written and electronic form. Each organisation with whom your information is shared will comply with the Data Protection Act 2018.

Please confirm by ticking each box that you agree to give the local authority permission to share information about you/your child for the following purposes:

☐ to gather information and evidence to aid us to decide about whether to carry out an Education Health Care (EHC) needs assessment

☐ to share information as part of an EHC needs assessment

☐ to share information as part of an annual review of an EHCP

☐ to share information where a learning delay may be discovered with the CCG/GP in order that an annual health check can be carried out.

☐ to disclose the EHCP and any supporting information to agencies and individuals who are responsible for commissioning or delivering provision as set out in the EHCP including for the purposes of consulting with all future prospective educational settings. Such agencies and services may include but are not limited to:


https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/398815/SEND_Code_of_Practice_January_2015.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/398815/SEND_Code_of_Practice_January_2015.pdf

Norfolk County Council ☐ Clinical Commissioning Groups ☐

Health services ☐

Educational establishments ☐

Early years settings ☐

Youth offending team or probation service ☐

Children’s Centres ☐

Department for Work and Pensions ☐

Voluntary Agencies ☐

For young people over compulsory school age, your parents or legal guardians ☐

Any other organisation or people you want us to contact, not listed above please list here:

Signature (parent/carer/young person): Print name:

SEND Code of Practice 2015 Disclosure of an EHC plan Relevant legislation: Regulations 17 and 47 of the SEND Regulations 2014

9.211 A child or young person’s EHC plan must be kept securely so that unauthorised persons do not have access to it, so far as reasonably practicable (this includes any representations, evidence, advice or information related to the EHC plan). An EHC plan must not be disclosed without the consent of the child or the young person, except for specified purposes or in the interests of the child or young person. If a child does not have sufficient age or understanding to allow him or her to consent to such disclosure, the child’s parent may give consent on the child’s behalf. The specified purposes include:

disclosure to the Tribunal when the child’s parent or the young person appeals, and to the Secretary of State if a complaint is made to him or her under the 1996 Act

disclosure on the order of any court or for the purpose of any criminal proceedings disclosure for the purposes of investigations of maladministration under the Local

Government Act 1974 disclosure to enable any authority to perform duties arising from the Disabled

Persons (Services, Consultation and Representation) Act 1986, or from the Children Act 1989 relating to safeguarding and promoting the welfare of children

disclosure to Ofsted inspection teams as part of their inspections of schools or other educational institutions and local authorities

disclosure to any person in connection with the young person’s application for a Disabled Students Allowance in advance of taking up a place in higher education, when requested to do so by the young person


disclosure to the principal (or equivalent position) of the institution at which the young person is intending to start higher education, when requested to do so by the young person, and

disclosure to persons engaged in research on SEN on the condition that the researchers do not publish anything derived from, or contained in, the plan which would identify any individual, particularly the child, young person or child’s parent. Disclosure in the interests of research should be in accordance with the Data Protection Act 1998 and wherever possible should be with the knowledge and consent of the child and his or her parent or the young person


Documents

20201120 PROFESSIONAL REFERRAL SEN SMMW V4 ... · Web viewWhere the Local Authority receives this form as a request from a health or social care professional we will then write out