SEND Locality Team

Request for Involvement Form 2015-2016

Child’s Name: / DOB: / Male/Female
School/Setting: / UPN: / Year Group:
Main Contact in School:
Statement/EHCP:
Name and Title:
Relationship to the child/young person:
Address:
Telephone Number(s):
Child’s first language:
Parent/Carer preferred language:
Is the child/young person an asylum seeker/refugee/CLA:
Summary of concern:
Summary of intervention and support already in place:
Relevant background (medical, family, educational history) to be completed jointly by parent/carer and setting:
Strengths and interests:
Parent/carer views (attach an additional sheet if necessary):
Purpose of professional involvement (e.g. questions to be answered):
Agency Involvement
Please record any involvement of other Children’s Services or Health Services (for example, Speech and Language Therapy).
Agency / Practitioner / Date/period of involvement / Current
Yes/No
Yes/No
Yes/No
Please describe support strategies (both successful and unsuccessful) that have already been implemented using targeted support (Elements 1 and 2 – of delegated SEN budget), including both quantitative and qualitative evidence of impact:
Need / Strategy / Date Implemented / Outcome / Date Reviewed
Primary Area of Need
Please number accordingly
Communication & Interaction / Reading / Social/Social Skills / Physical/Medical
Language / Writing / Emotional / Motor Skills
Listening and Attention / Maths / Mental Health / Sensory
Speaking
Other: …………………………………………………………………………………………………
Levels of Functioning
Please delete Section A/B/C dependant on setting:
Section A
EYFS / Age in months / Age in months / Age in months
Personal, Social and Emotional Development / Self-confidence and awareness / Managing feelings / Relationships
Physical Development / Moving and handling / Health and self-care
Communication and Language / Listening and attention / Understanding / Speaking
Literacy / Reading / Writing
Mathematics / Numbers / Shape, space and measures
Understanding the World / People and communities / The world / Technology
Expressive Arts and Design / Exploring media and materials / Being imaginative
Section B
Attainment & Progress National Curriculum/P Level APS (average points scores) Primary:
(If not applicable please give equivalent with appropriate explanation)
Date / Reading / Writing / Maths / PHSE
Standardised Tests
Name of Test / Date / Chronological Age at time of testing / Standardised Score / Percentile
Section C
Attainment & Progress National Curriculum/P Level APS (average points scores) Secondary:
(If not applicable please give equivalent with appropriate explanation)
Date / English / Maths / PSHE
Standardised Tests
Name of Test / Date / Chronological Age at time of testing / Standardised Score / Percentile
Parent/carer:
I consent to involvement from the SEND Locality Team
Signed ………………………………………………… Date ………………………………..
This information helps us to understand what support is needed. This means that we may need to share relevant information with other professionals where appropriate.
Setting:
Class Teacher name ……………………………….
Signed ……………………………………………….. Date …………………………………
SENCo/Inclusion Manager name ………………………………
Signed ………………………………………………. Date ………………………………..
Please ensure that this form contains parental consent/signature before returning:
Guidance Notes:
Before seeking specialist advice, it is expected that:
·  The SENCo ensures Quality First Teaching Strategies are in place
·  There will have been targeted and personalised interventions/strategies in place for at least one term / 2 assess, plan, do and review cycles. Telephone advice can be sought from your lead specialist teacher to support this process.
·  The request for involvement will have been discussed with your lead specialist teacher
Please ensure the following are attached:
o  Attendance printout – last 12 months
o  Information on fixed term and permanent exclusions
o  Current Provision Map/IEP or equivalent, including review and impact of previous two assess, plan, do review cycles
o  FACT/FACT Plus including details of implementation of at least one assess, plan, do, review cycle*
o  PEP (if CLA)
o  Current reports from agencies involved
* If you have any questions about the use of the FACT/FACT please speak to your lead specialist teacher
Please attach where relevant:
o  Boxall/Emotional Literacy Assessment
o  Analysis of behavioural incidents
o  Example of unaided work in priority area
o  Environmental Checklist, Communication & Interaction or Dyslexia/Literacy Difficulty audits
Please return too:
Sensory Team:
Uday Thakrar (HI, VI, MSI)

North:
Sue Morgan:

Central:
Lisa Munro

South:
Emma Richards

Electronic copies can be downloaded at: https://www.milton-keynes.gov.uk/schools-and-lifelong-learning/special-educational-needs