Education, Health and Care Plan Assessment Post 16 Student Request Form

Education, Health and Care Plan Assessment –Post 16 Student Request Form

Personal Details
Student’s Surname / First names
Address
Postcode / Date of birth
Gender
Home Language
Home phone no. / Email address
Mobile no. / Preferred contact method

If you are under 18, pleasetellusyourparents’ or carers’ namesandcontact details. Bylaw,wehaveto knowthe details of everyone who has parentalresponsibility for you, if applicable. We will invite them to take part in the assessment process.

If you are over 18, and would like us to involve your parents or carers in this process, please give us their contact details below.

Parent / Carer 1 / Parent / Carer 2
Name / Name
Address
Postcode / Address
Postcode
Status: Mother/Father/Legal Guardian/Carer
(delete as appropriate) / Status: Mother/Father/Legal Guardian/Carer
(delete as appropriate)
Telephone no. / Telephone no.
Email address. / Email address.
Why do you believe you need an EHCP?
What are your wishes and hopes for the future?
What are you worried about or what would you like to change?
(Add extra sheets of paper if you want to)
What Schools/Colleges have you attended, and what accreditation have you already achieved?
School / College Name and Address / Dates Attended / Qualifications / Accreditation gained
Student’s GP (please include medical centre, practice name, address and postcode)
Are you eligible for Disability Living Allowance/ Personal Independence Payment? Yes/No / If yes, which level? High/Medium/Low
Please tell us about your Special Educational Needs
Remember to include any learning needs, physical or health needs, communication or sensory needs, and any social, emotional or mental health needs.
What support are you currently receiving?
(Add extra sheets of paper if you want to)
Please include copies of any recent reports or assessments when you submit your application
Which Professionals or Services are currently supporting you?
Service / Professional’s name / Contact Details

If the Local Authority decides to go ahead with an assessment, would you like us to consider providing you with support from a Key Worker? Yes/No(delete as appropriate)

Would you like another adult to act on your behalf (e.g. your parent or carer)?Yes/No

If yes please give details here:

Declaration

AspartofmyapplicationforanEducation, Health and Care assessment Ihaveread andunderstoodtheinformationabove. Yes/No (delete as appropriate)

I giveconsenttoan assessment being undertaken and information regarding me and my family being shared by and with relevant professionals and services. Yes/No (delete as appropriate)

I accept that information will be kept on a database to ensure the quality of the service.Yes/No

Student’s Signature:Date:

If you have completed this form on behalf of a student who is unable to give their signature, please provide your contact details here:

Nottingham City SEN Service, Glenbrook Management Centre, Wigman Road, Bilborough, Nottingham, NG8 4PD

Email: Telephone: 0115 876 4300