DRAFTING DOCUMENT – PROPOSAL FOR AN EHC ASSESSMENT
0-25 SEND Statutory Assessment Team- PRIMARY PROPOSAL FORM
DRAFTING DOC_ PRIMARY _Version 2bSEPTEMBER 2014 Not protectively marked
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PLYMOUTH CITY COUNCIL
NB:
This document has been designed as a tool to support you in drafting the information
that you will submit to the us via the Online Proposal form as discussed in the SENCO conference.
Please do not send this form to us as it will not be accepted as a Proposal – and will be returned to you. When you are happy with the information (and are ready to copy it across to the online form) please email and ask for us to issue you with an “EHC Proposal login andpassword” that you will need in order to save and submit you online form.
*Indicates a mandatory field
Section 1 – Child/ YP details
*Surname of Child / Young Person:
*Other names:
*Date of birth:
*Contact phone number:
Ethnicity:
*Gender:
Male FemaleNHS Number:
*Unique Pupil Number (UPN):
*National Curriculum (NC) Year Group (let us know if this is offset):
*Language used at home:
Religion
* Educational Placement Currently Attended
*Date of admission to current educational placement:
*Child / Young Person’s home address:
*If Social Services are involved with the Child / Young Person, what is the case status?
DROP DOWN: Options are…Not Applicable/ Looked After Child/ Child in Need/ Child Protection/ Common Assessment Framework/ Team Around Me
Is there a CAF (Common Assessment Framework) orEarly Help Assessment or TAM (Team Around Me)?
Yes NoIf Yes, please provide the name and contact details of the Lead Professional
*Is the Child / Young Person classified as FSM (Free School Meals)?
Yes No*Does the Child / Young Person currently have a parent / carer serving in HM Forces?
Yes NoSection 2– Parent/Carerinformation and child/YP strengths
Please list the names and addresses of all persons with Parental Responsibility for the above named Child / Young Person. This should include Parents / Carers and, if the Child / Young Person is looked after by the Local Authority, the responsible Social Worker.
Parent 1* Name (including title):
* Parent / carer date of birth (we need this information for data validation):
* Relationship to Child / Young Person:
* Address (if different to Child / Young Person):
* Telephone contact details:
How would you like us to communicate with you?
DROP DOWN: Options are…
Telephone / Email / Letter
If you selected e-mail as your preferred contact option, please enter your e-mail address:
How many additional parents or carers have parental responsibility for the child / young person?
DROP DOWN: Options are…None / One / Two
NB: You will only need to complete the Parent 2 & 3 fields if they are applicable to you.
Parent 2Name (including title):
Parent / carer date of birth (we need this information for data validation):
Relationship to Child / Young Person:
Address (if different to Child / Young Person):
Telephone contact details:
How would you like us to communicate with you?
DROP DOWN: Options are…
Telephone / Email / Letter
If you selected e-mail as your preferred contact option, please enter your e-mail address:
Parent 3 (if required)
Name (including title):
Parent / carer date of birth (we need this information for data validation):
Relationship to Child / Young Person:
Address (if different to Child / Young Person):
Telephone contact details:
How would you like us to communicate with you?
DROP DOWN: Options are…
Telephone / Email / Letter
If you selected e-mail as your preferred contact option, please enter your e-mail address:
Are there any special circumstances we should know about?
For example, Parent 1 is not to have contact with Parent 2
Please provide a summary that describes the Child / Young Person’s strengths and needs in consultation with parents or carers (you may wish to upload a “This Is Me” profile).
*At their educational placement
*At home
Upload "This Is Me" profile documentPath to file to upload when submitting proposal online:
Title of document
Description of document
Section 3 – Areas of need overview
Using the headings below, describe the Child / Young Person's current areas of need and difficulty with indication of how they are severe, complex and enduring.
Communication and interaction* Is this a consistent area of need?
Yes No
Please describe in detail
Cognition and learning
* Is this a consistent area of need?
Yes No
Please describe in detail
Emotional, social and mental health difficulties
* Is this a consistent area of need?
Yes No
Please describe in detail
Sensory and physical
* Is this a consistent area of need?
Yes No
Please describe in detail
Section 4– Main presenting need(s) including health needs
Provision, attainment and progress information
* Child / Young Person’s main presenting needDROP DOWN: Options are…
Communication and Interaction/ Cognition and Learning/ Emotional, Social and Mental Health Difficulties/ Sensory and Physical
* Please list the names of relevant professionals involved with supporting the Child / Young Person and include dates of any reports.
If chosen Communication and Interaction from drop-down list please name the relevant professionals involved supporting the child with this need and dates of reports E.g. CIT, S&L
If chosen Cognition and Learning from drop-down list please name the relevant professionals involved supporting the child with this need and dates of reports E.g. EP
If chosen Emotional, Social and Mental Health Difficulties from drop-down list please name the relevant professionals involved supporting the child with this need and dates of reports E.g. CAMHS, CDC
If chosen Sensory and Physical from drop-down list please name the relevant professionals involved supporting the child with this need and dates of reports E.g. CDC, Advisory Teacher, Paediatrician, OT
Child / Young Person’s secondary presenting need
DROP DOWN: Options are…
Communication and Interaction/ Cognition and Learning/ Emotional, Social and Mental Health Difficulties/ Sensory and Physical
Please list the names of relevant professionals involved with supporting the Child / Young Person and include dates of any reports.
If chosen Communication and Interaction from drop-down list please name the relevant professionals involved supporting the child with this need and dates of reports E.g. CIT, S&L
If chosen Cognition and Learning from drop-down list please name the relevant professionals involved supporting the child with this need and dates of reports E.g. EP
If chosen Emotional, Social and Mental Health Difficulties from drop-down list please name the relevant professionals involved supporting the child with this need and dates of reports E.g. CAMHS, CDC
If chosen Sensory and Physical from drop-down list please name the relevant professionals involved supporting the child with this need and dates of reports E.g. CDC, Advisory Teacher, Paediatrician, OT
Health
Does the Child / Young Person have any health needs? For example, diagnosis of condition or need:
What health provision is in place to meet these needs?
Provide names and details of any health professionals involved
Section 5 – Care needs and previous educational provision
CareProvide any details of care needs, e.g. Social Care, Short Breaks, AHELP, and Inclusion Works.
Education
For each school year please note the details of support, intervention and resources (indicate whether this is in-class,small group or individual)the impact of these interventions(including dates of other agencies involved).
Please make use of the formatting tools to make your answers easy-to-read (you can use bold, italics, bullet points and indent text)
Year 0/ R
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Other
Section 6– Current educational provision
Summarise how you have used funding allocated to the educational provider to support the Child / Young Person’s needs. This may include any or all of the following: ME2 Funding / SEN delegated funding/ AEN/ notional funding or if appropriate Pupil Premium / Young Person Premium
Please complete the timetable below indicating the current support or provision in place for the named Child / Young Person (please indicate whether this is in-class, small group or individual). We recommend you use bullet points to separate the support that takes place in the morning, at lunch and in the afternoon.Monday
Tuesday
Wednesday
Thursday
Friday
Section 7 – Previous setting(s) attainment levels
Please record EYFS Phase of Development.
Three prime areasDate recorded
Child’s chronological age at assessment
Listening and attention
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Understanding
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Speaking
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Moving and handling
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Health and self-care
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Self-confidence and self-awareness
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Managing feelings and behaviour
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Making relationships
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Four specific areas
Date scores recorded
Reading
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Writing
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Numbers
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Shape, space and measure
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
People and communities
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
The world
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Technology
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Exploring and using media and materials
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Being imaginative
Please select the phase age in months
0 - 11 8 – 20 16 - 26 22 - 36 40 – 60+ 30 – 50
Please indicate whether this is High or Low:
Section 8– Current setting record of progress
Please record the Early Years Goals and National Curriculum levels of equivalent progress.
ReadingYear 0 / R
Year 1
Year 2
.
Year 3
Year 4
Year 5
Year 6
Writing
Year 0 / R
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Numeracy
Year 0 / R
Year 1
Year 2
.
Year 3
Year 4
Year 5
Year 6
Phonics
Year 0 / R
Year 1
Year 2
.
Year 3
Year 4
Year 5
Year 6
Section 9 – Summary of provision needs
*Summarise what you would provide for Child/Young Person’s learning that cannot be met from within the educational placements existing SEN resources.
Section 10– Evidence and agreement
Please attach the following evidence which must be submitted with this request in order for the Single Multi-Agency Panel to make an informed decision.
Recent Early SEND Support plans: Including the “This Is Me” profile and IEP (or similar)Path to file to upload when submitting proposal online:
Title of document
Description of document
Copies of relevant reports and evidence of involvement from specialist support services (within the last 12 months).
Path to file to upload when submitting proposal online:
Title of document
Description of document
Copies of other agency reports, including Health and Social Care, where relevant
Path to file to upload when submitting proposal online:
Title of document
Description of document
By submitting this request you are confirming that parents and Headteacher/SEN Co-ordinator have been involved in the completion of this form and that any relevant information submitted can be shared with members of our Multi-Agency Panel.
* I agree to the above terms and conditions. Please note without your agreement this request cannot proceed.
Yes
* Name and job title of person completing the form:
FINAL CHECKLIST
Yes / N/A
* Have you asked the parent/carer if there is any further info that they wish to submit?
* If so, has this been included in the proposal?
* Have you given the parent information about Plymouth Parent Partnership?
* Has the educational advice and information been provided after consultation with a person who is qualified to teach pupils or students with vision or hearing impairments or both?
SAVE AND SUBMIT
DRAFTING DOC_ PRIMARY _Version 2 SEPTEMBER 2014 Not protectively marked
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