Surrey Family Service –Supporting Children Team

Request for support from the SEND Team or Early Education and Childcare Team

Please complete this form with as much information as possible.Section A should be completed for all requests. Section B should be completed if requesting support for an individual child.

Section A:

Details of person requesting support
Name / Role
Agency/organisation name, address and Ofsted URN
E-mail address / Telephone number
Date form completed

Please complete the belowquestions (with as much information as possible):

What is working well? (What have you tried already?What have you put in place? If requesting support for a specific child then focus on what works well for the child)
What are you worried about? (a child’s sleeping, eating, physical development, communication and language, emotional development or behaviour, SEND, aspects of the EYFS including practice, policies or procedures, high number of vulnerable groups in current cohort - see cohort information below, high levels of EAL,)
What do you want to happen?(what support would you like. Following an Ofsted outcome, practice, the learning environment, staffing, safeguarding/child protection concern or support with SEND processes)
Cohort information – number of children who are:
looked after (Fostered) / Under Child in Need / In receipt of Free Early Education for two year olds (FEET)
On a Child Protection Plan / With a Special Educational Need or Disability / In receipt of Early Years Pupil Premium (EYPP)
Under Early Help / In receipt of Disability Access Fund (DAF) / In receipt of deprivation funding
In receipt of 30 hours Funded Early Education

For individual child referrals:

Section B:

Child’s Forename
Child’s Surname
Child’s Date of Birth
Gender
Ethnic Origin and Home Language
HomeAddress
Has parental consent been obtained for this referral? / Yes / No
Days and time child attends the setting
Date child started at setting

Parental/family details:

Name
Relationship to child
Address (if different from above)
Telephone Number and email.
Parental responsibility for above named child / Yes / No
Does the child have a child protection plan?Please highlight / Yes / No
Is the child a looked after child?Please highlight / Yes / No
Has an Early Help Assessment been completed for this child/family?Please highlight / Yes / No
Please print name of referrer as electronic signature.

Data Protection Act 1998. Surrey County Council (the ‘Council’) respects your privacy rights and is committed to ensuring that it protects your details, the information about your dealings with the Council and other information available to the Council (‘your information’). In accordance with the Data Protection Act 1998, the Council will use your information, for the purpose of providing support to children, to (a) deal with your requests and administer its departmental functions, (b) meet its statutory obligations, and (c) prevent and detect fraud. The Council may share your information (but only the minimum amount of information necessary to do the above and only where it is lawful to do so) with appropriate departments and agencies in accordance with the Multi Agency Information Sharing Protocol (MAISP). Further details including a copy of the MAISP can be found at . If you would like to apply for access to the information we hold about you please send a written request to the above address. This information will be held electronically.

Please return completed form via egress to:

NE Area (Elmbridge, Spelthorne, Epsom and Ewell) –

SE Area (Mole Valley, Tandridge, Reigate and Banstead) –

NW Area (Woking, Runnymede, Surrey Heath) –

SW Area (Guildford, Waveley) –

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Supporting Children Team –Request/referral