Parent/Carer Application Form V17.2

SEN & Disability Team

New request for an Education, Health and Care Needs Assessment

1. Details of child/young person

Family Name: / First Name(s):
Preferred Name: / DOB: / Click here to enter a date. /
Ethnicity: / Religion:
Gender: / Male ☐Female☐ / Child Looked After:
Name of Local Authority:
Section: / Yes ☐No☐
Section 20 ☐Section 31☐
Address: / Postcode:
First Language (inc British Sign Language): / Is an interpreter required?
Help with written English?
British Sign Language used? / Yes ☐No☐
Yes ☐No ☐
Yes ☐No ☐
School/college/early years setting attended:
Date of Admission:
When did they start here? (MM/YYYY) / Click here to enter a date. /
Other schools/colleges/early years settings attended during the last 18 months:

2. Details of the parents/carers

Full names of parents/carers:
Address (if different from child/young person): / Postcode:
First Language (inc British Sign Language): / Is an interpreter required?
Help with written English?
British Sign Language used? / Yes ☐No ☐
Yes ☐No ☐
Yes ☐No ☐
Telephone number: / Mobile number:
Is either parent in the Armed Forces: / Yes ☐No☐ / Do you have access to an email account?: / Yes ☐No☐
Email address:
Please advise how and when is best to contact you:
Full names of anyone else with parental responsibility for the child/young person:
Relationship to child/young person:
Address (if different from child/young person): / Postcode:
First Language (inc British Sign Language): / Is an interpreter required?
Help with written English?
British Sign Language used? / Yes ☐No ☐
Yes ☐No ☐
Yes ☐No ☐
Telephone number: / Mobile number:
Do you have access to an email account?: / Yes ☐No ☐
Email address:
Please advise how and when is best to contact you:

3. Professional Involvement

If you have had discussions with other professionals or your child has been seen by professionals, please list their names below. If your child is of school age, we would advise you to have a discussion with the Head Teacher/SENCo about your child’s special educational needs before returning this form. If you wish to provide any up to date and relevant reports in support of your request for assessment, please ensure that these are sent to the London Borough of Redbridgeat the address at the end of this form within 15 days.

Advisory Teacher/Outreach Worker:
Medical Specialist:
Speech and Language Therapist:
Occupational Therapist:
Physiotherapist:
Educational Psychologist:
Social Worker:
Family Worker:
Other:

TO BE COMPLETED BY PARENT or CARER

4. About the child/young person(continue on extra sheets if necessary)

Please provide a brief history of your child’s development and the support they have received from any education, health or social care services. (You may wish to think about their health, eating/sleeping, developmental milestones and self-care/self-help skills etc.)
What do you consider to be your child’s educational strengths, needs and difficulties? (You should think aboutnot only their academic progress, but also social/friendship skills, attitude towards education, behaviours that do/do not help them to learn).
Are there any health or care needs that in your view are affecting your child’s education?

INFORMATION SHARING AND CONSENT FOR EDUCATION, HEALTH & CARE (EHC) ASSESSMENT

London Borough of Redbridge will need to gather information from and share information with a number of professionals that are involved with your child so that a decision can be made whether to conduct an EHC needs assessment for your child. We may also use the information for the assessment if it has been agreed to go ahead.

The information that you and professionals provide about your child will only be shared with your consent. Information shared may relate to any or all of a child’s education, health and social care needs.

The only time we would share information without your consent is:

to find out urgently if a child is at risk of harm or we need to help a child who is at risk of harm;
to help an adult who is at risk of harm;
to help prevent or detect a serious crime.

By signing this form I/we agree to the gathering and sharing of information between my child’s school (or young person’s educational setting),education services, health services, social care or other professionals as necessary. I also agree for the information to be passed on to proposed pre-school/schools and post 16 establishments that have been proposed for my child.

I also agree that my child may be seen by an educational psychologist who can carry out assessments at school and offer advice to the school.

Child’s full name: Date of birth:

Parent / carer’s name(s):

Relationship to child:

Signature of Parent/carer: Date:

Please ensure that at least one person with parental responsibility signs this form.

Is there any individual or organisation you would not wish information to be shared with? Please provide details here along with your reasons for not wishing to involve them.

I/we do not give consent to share information with the following named people, organisation and/or services; we understand that by doing so, this may create difficulties in providing the support needed for her/him:

Name of organisation:

Reason(s) for not sharing information with them:

Please return this form to:

New Assessment Requests

SEN DisabilitiesTeam

9th Floor Rear, Lynton House

255-259 High Road

Ilford

IG1 1NY

Tel: 020 8708 8210

Email:

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