20201120 EY REFERRAL SEN MWSM V5

Early Years - Request for an Education Health Care (EHC) Needs Assessment

This form is to be used by Early Years professionals only to request an EHC needs assessment for a child or young person. If you are a parent, carer, young person or other professional / setting who would like to make a request, please do not use this form.

This document is to be used by Early Years professionals and settings to request an EHC needs assessment.

Where the Local Authority receives this form as a request we will then write out to health and social care professionals who may be involved with the child, 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:- csehcp@norfolk.gov.uk

Please note the involvement of other professionals is essential to help evidence that an informed Graduated Response/approach 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/approach 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: to be completed by Professional

All relevant assessments/reports/diagnosis

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Attendance Record

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Support Plan – most recent

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View/Wishes & Family Conversation Form Appendix 1 – Must be completed by parents

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DP1 consent (signed by parent/s or legal guardian) Appendix 2 – Must be completed by parents

☐

Progress data

☐

This form is intended to be filled out electronically. The referral form should be completed by the professional with consultation if needed with parents.

Who is making the request/providing information?

Name:

Position / title:

Contact details

Telephone number:

Email address:

Child/young person’s personal details

The professional is expected to complete the referral form themselves in liaison with parents

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 ☐

Do any of the following apply?

Continuing Care

Yes ☐ No ☐

Adopted/special Guardianship

Yes ☐ 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

You need not complete this section if the current setting is meeting the child/young person’s educational needs and providing appropriate provision

Educational Needs

ASSESS – Please specify assessments/ reassessments & results of assessments carried out over time. NB include dates of assessments

PLANNING – Describe here how you have worked with the Child & family to meet their SEN – please include evidence of person centred planning

REVIEW/ OUTCOMES – What impact does this have on child’s learning generally, for example, classroom practice? Evidence of impact to be included.

FUTURE SUPPORT – Please describe in detail the support & provision you believe the Child requires to meet their SEN, please ensure this is specific and quantified.

Communi-cation & Interaction

Cognition & Learning

Social Emotional & Mental Health

Sensory and / or Physical Needs (including health / medical needs that impact on access to learning)

If the identified SEN provision required is additional to and different from those provided for all children, please provide detail below.

Additional support needs identified and being accessed for the child.

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? (any services being provided for the child, e.g. OT, Physio, SaLT, Portage etc)

Total Cost (if known) £__________________________________

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 SEN Inclusion fund, DAF, bespoke training.

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 Care

Access through Technology

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Child and Adolescent Mental Health Services.

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Children with Disabilities Social Care

☐

Virtual School Children In Care / SEN

☐

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 (feet)

☐

Speech and Language

☐

Armed Service Children’s Education Advisory Service

☐

Paediatrician

☐

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

☐

Continuing Care

☐

Physiotherapy

☐

Other

☐

Other

☐

Other

☐

Other

☐

Other:

☐

Other:

☐

Other:

☐

If you have any reports from any professional which related to the child and are dated within the last 12 months, please send them in with this referral.

Professional Contact Details

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?

What support is being provided?

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?

What support is being provided?

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?

What support is being provided?

Section A: child’s story so far

Child’s history. Please keep information current, but include relevant history relating to education, care and health. Please include aspirations of and for the child. Describe what is happening, where and when, how often and for how long, giving examples if possible. Is there anything else that may be influencing the current difficulties? Include any current medications or treatments and any reasons or changes in attendance.

You can list your concerns using bullet points.

Primary Special Educational Needs

Rank in order if more than one in diagnosis field – 1 being the most significant need

Primary Special Educational Need

Yes/No

Diagnosis

Communication & Interaction

Yes ☐ No ☐

Social Emotional & Mental Health

Yes ☐ No ☐

Cognition & Learning

Yes ☐ No ☐

Sensory &/or Physical Needs

Yes ☐ No ☐

Additional Needs

Yes ☐ No ☐

Attendance

Current attendance record – please provide as much information as possible or attach an attendance record. Early Years settings should specify number of hours the child is registered to attend along with those actually attended.

Period (Dates)

Possible attendance (No of sessions/hours) per week

Actual attendance (No. of Sessions per week)

Universal Hours

Extended Hours

Education – Attainment and Tracking Data

Please consider the following:

· Is the pupil making good progress towards meeting or exceeding the expected level of development for their age?

· 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?

Please also submit last term and last end of year attainment and tracking data or utilise the tables below

Please rate each of the early learning aspects in the prime areas of learning below.

1 = emerging, 2 = expected, 3 = exceeded

Early Years Foundation Stage

Communication & Language Development

Listening & Attention

Understanding

Speaking

Physical Movement

Moving & Handling

Health & Self Care

Personal, Social & Emotional Development

Self-confidence and self-awareness

Managing feelings and behaviour

Making relationships

Please rate each of the early learning aspects in the specific areas of learning below.

Literacy

Reading

Writing

Mathematics

Numbers

Shape, space and measures

Understanding of the World

People and communities

The world

Technology

Mathematics

Exploring and using media and materials

Being imaginative

NOTE: The commentary box (below) for development and tracking data must still be completed to support the interpretation of the data you are providing.

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

Continuation of child 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

Language child hears at home

Language child hears at home

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 with the parents and child if the child is able to

2

20201120 EY REFERRAL SEN MWSM V5

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 Contacts

You 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 form

Please 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 Others

Please provide details of any people significant to .

Name

Relationship

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

Name

Support offered

Regularity

(Weekly, Monthly, Yearly)

Services

Arts & culture

Education

Physical Activity

Family & Friends

Faith & meaning

Other

e.g. Grandparents (Names)

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

Monthly

Y

5. Child/Young Person’s Views

My story so far

Child’s history including the views of parents / carers and professionals about child’s needs now and in the future. Please keep information current but include relevant history and any information you feel is relevant.

Any other information you wish to share?

Tell us about your family, education setting and friendships (it will be helpful to complete this with your Early Years Provider)

What do you enjoy? Who with? What are you good at? What are your special interests? Where do you go to do these things? Do you face any challenges or barriers accessing these activities?

At Early Years Setting

Outside of early Years Setting

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

What makes 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 us to communicate with you? 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 views

What are your child’s strengths in the following areas?

Communicating and listening

Learning and understanding

Developing and maintaining relationships/friendships

Physical and independent skills

What are your aspirations, goals, wishes, hopes and ambitions for your child, in the short and long term?

What skills and support do you feel they need to develop to achieve this?

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:

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

Early Years EHCP Referral Form Jan 21 v12