Early Years and Childcare referral form

For SEN services to individual children and their families

A referral to the Early Years and Childcare service will lead to the family being contacted and their needs discussed. As a result of this a service may be offered which could include:

·  Support to access universal services e.g. children’s centre services, an early education place with a registered provider.

·  Support to access targeted services e.g. an invitation to join a Little Stars group (A Portage approach based in a Children’s Centre).

·  Early learning together - A home based early education service (formerly Portage)

·  Educational advice.

*Note Please type the form where possible or if hand written please ensure it is clear

Childs Name: / Child’s home address
D.O.B:
Age:
Parent/carer(s) names / Contact number
Setting/School child attends: (if applicable)
Attendance /
Mon Tues Weds Thurs Fri Sat Sun
Referrer Name
Job Role
Contact Number
Email address
Other agencies involved? (Eg. Health Visitor, Paediatrician, SALT, Social Care, 1st Base, Physio, OT, CDC, Children’s Centre). / SEND Code of Practice:
If the child has a SEND which broad area is appropriate?
Please indicate contact names for involved agencies: / Communication and interaction
Cognition and learning
Social, emotional & mental health
Sensory and/or physical needs
Is the child a Looked After Child? / Yes No
Has a CAF been completed for this child? / Yes No
Parental permission for EYC involvement (delete as appropriate)
·  I give permission for my child to be referred to the Early Years and Childcare service
·  I understand that if the Early Years and Childcare service becomes involved, information will be shared in accordance with the Data Protection Act and may be shared with other agencies / professionals where appropriate.
Signed: …………………………………………………………… Parent / Guardian
Date: ……………………….
Please answer the following questions as this will help us plan our involvement.
This should be shared with parents / carers.
What are your concerns?
What are you already doing regarding your concern?
Please attach current and recently reviewed IEP (where available).
What progress have you noticed?
What are the child’s strengths?
What difference would you like EYC involvement to make?
Is there anything else we should be aware of?
Are there any known risks if home visits will be required?
What is the child’s first language (if it is not English)?
Signed by referrer:
Date:

Return the completed form by post to:

Early Years and Childcare Service (B1-F3)

Suffolk County Council

Endeavour House

8 Russell Road

Ipswich

IP1 2BX

Tel: 0345 60 800 33

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Version 6

2014-09-05