Requestfor an Education Health and Care (EHC) needs assessment form for Educational Settings
This form must be word processed and a copy saved electronically until you have been informed of the outcome of the request for EHC needs assessment. Please read the local authority’s Guidelines for educational settings on requesting an EHC care needs assessment document before completing this form and the Guide to theEducation, HealthandCare (EHC) needsassessment process.
Name of educational settingChild or young person’s details
Legal surname
(Also known as, if appropriate) / Other names
Date of birth / Age / NHS No.
Gender / Ethnicity / Forces family / Yes / No
Home address
Postcode
Young person 16+ email
Young person 16+ telephone
Young person 16+ mobile
Person/s with legal parental responsibility details
Title / Initial / Surname
Address if different from child or young person
Postcode
Telephone / Mobile
Title / Initial / Surname
Address if different from child or young person
Postcode
Telephone / Mobile
To be completed by young person aged 16+
The request for an education health and care needs assessment has been discussed with me / Yes / No
I agree with this request / Yes / No
I wish my parents to be copied into all correspondence / Yes / No
I agree for relevant professionals to share information with agencies about me. This consent will be valid for the duration of the EHC needs assessment and, if an EHC plan is issued, for the duration of the plan / Yes / No
I have read and accept the data protection information detailed below
Confidentiality Please state if there is anyone including professionals that you do not want your information shared with
Name
Signature
Young person aged 16+ / Date
To be completed by person/s with legal parental responsibility( when applicable)
Information about this request for an education health and care plan has been shared with me/us / Yes / No
I agree with this request / Yes / No
I agree for relevant professionals to share information with agencies regarding my child. This consent will be valid for the duration of the EHC needs assessment and, if an EHC plan is issued, for the duration of the plan / Yes / No
I have read and accept the data protection information detailed below
Confidentiality Please state if there is anyone including professionals that you do not want your information shared with
Name
Signature
Person/s with legal responsibility / Date
Name
Signature
Person/s with legal responsibility / Date
Data Protection Act –Privacy Notice
We, Children, Schools and Families Directorate, Cornwall Council, New County Hall, Truro, TR1 3AY, Data Protection Registration Number: Z1745294 are committed to protecting and respecting your privacy.
This information is being collected by Statutory SEN Service on behalf of Cornwall Council as Data Controller for the purpose of determining the educational needs of the named individual.
Data on you or your child may also be shared with other relevant professionals who are SEN Support Services, Educational Psychologist, Child Health, Schools/Colleges, Independent Specialist Providers, CAMHS, Social Workers, Transport Team and the Speech and Language Therapy Service to inform their work. The data held relating to the delivery of support by the relevant Support Service(listed above) to your child will be used both for the provision of services and also for performance and service planning. This information will be held in a secure environment until the individuals 30th birthday in accordance with the CSF data retention policy after which time it will be destroyed in a secure manner.
A copy of our Privacy Notice can be found at Privacy Notice sets out the basis by which any personal data we collect from you, or that you provide to us, will be processed by us, in accordance with the General Data Protection Regulations (GDPR) and the Data Protection Act.
For further information or assistance on Data Protection matters, please contact the Practice Development and Standards Service on 01872 327617 or e-mail
Or the Councils Data Protection Officer
You have the right to withdraw consent to the processing of your data at any time and your further rights as to how we handle your data can be found by following the above link. Should you wish to withdraw your consent please contact the Statutory SEN Service at Note that if you do not tick the box below then the Statutory SEN Service will not be able to continue with the process.
Support to access process any communication requirements of the young person or person/s with legal parental responsibility to enable full engagement in this process e.g. British Sign Language, translationInsert or delete rows as required
Services/professionals involved with the child or young person in relation to their special educational needs e.g. Educational Psychologist, Speech and Language Therapist, Social Worker, Health Visitor, Medical professionalName of Service / Named Professional / Address / email / Tick if seen in the last year / Tick if report enclosed
Person completing the form on behalf of educational setting
Name / Role
Address of educational setting
Postcode
Email / Telephone
Signature / Date
Add or delete rows as required
Checklist of attached evidenceThis should include details of nature and level of provision though the graduated response over time and the impact of this support / Appended
Graduated cycles of assess-plan-do-review at SEN support / Yes / No
Annotated timetables showing hours, group sizes, support in place / Yes / No
Evaluation and review of the impact over time of targeted programmes/interventions / Yes / No
Attainment and tracking data for the child or young person / Yes / No
Example of current aided work, if appropriate, dated and annotated / Yes / No
Example of current unaided independent work, dated and annotated / Yes / No
Written reports from external professional (ideally less than 12 months old) / Yes / No
Evidence of how the external professionals’ recommendations have been implemented and reviewed / Yes / No
The views, aspirations and wishes of the child or young person / Yes / No
The views, aspirations and wishes of the parent/s (if appropriate) / Yes / No
Other (please specify) / Yes / No
Other (please specify) / Yes / No
Other (please specify) / Yes / No
The next part of this form must start on a completely separate page and not back on to the information you have provided so far. Please insert blank pages if this is required
Part 1
Education Health and Care (EHC) Needs Assessment
Educational Advice
1:1 / Legal surname of child or young person Also known as, if appropriateOther names
Date of Birth / NHS Number
1:2 / Background context including record of schools/settings previously or concurrently attended
1:3 / Attendance percentage and comment
1:4 / What are the main forms of communication that the child or young person is able to use? How can they provide their views?e.g. speaking to trusted adult, eye contact, writing, picture exchange (PECS)
1:5 / What are the child/young person’s views about their education?
How do you know this?
1:6 / For a child under the age of 16 what are the views of the person/s with legal parental responsibility about their child’s education and progress? This section also needs to be completed for young people over the age of 16 who have been assessed under the Mental Capacity Act 2005 not to have the capacity to make a decision about this aspect of their education.
1:7 / Communication and interaction
What is working well and strengths
Identified special educational needs
Provision at SEN support
1:8 / Cognition and learning
What is working well and strengths
Identified special educational needs
Provision at SEN support
1:9 / Social, emotional, mental health
What is working well and strengths
Identified special educational needs
Provision at SEN support
1:10 / Sensory and or physical needs
What is working well and strengths
Identified special educational needs
Provision at SEN support
1:11 / Summary of provision at SEN support
1:12 / Child or young person’s level of academic attainment and rate of progress over the previous three terms
1:13 / Information and evidence, if appropriate, that when progress has been made it has only been as a result of sustained support and instruction over and above that which is normally provided at SEN support
1:14 / For a young person who has completed the compulsory stage of their education, how will accessing further education, training or apprenticeship build on earlier learning and support transition into adulthood?
If an EHC needs assessment goes ahead the educational setting will be prompted at the appropriate time to complete Part 2 of this form
Part 2
Education Health and Care (EHC) Needs Assessment
Educational Advice
2:1 / Any additional or significantly different information about the child or young person’s special educational needs since the request was madeEducational Outcomes and Provision
It is expected that every setting/school will provide high quality teaching that is differentiated, personalised and age appropriate for all children and young people, including those who are at SEN support. Provision which is ‘additional to and different from’ refers to highly personalised and more intensive interventions, over and above those offered as part of SEN support.
Set out below the outcomes that you feel should be put into place for the child or young person over the next three to four years and the provision required. The outcomes and provision should relate to the needs identified in Part 1of this form.
Add or delete rows as required
2:2 / Communication and InteractionOutcome
Special educational provision
Outcome
Special educational provision
Add or delete rows as required
2:3 / Cognition and learningOutcome
Special educational provision
Outcome
Special educational provision
Add or delete rows as required
2:4 / Social, emotional, mental healthOutcome
Special educational provision
Outcome
Special educational provision
Add or delete rows as required
2:5 / Sensory and or physicalOutcome
Special educational provision
Outcome
Special educational provision
Add or delete rows as required
2:6 / Year 9 onwards preparing for adulthood Training work employment and independent livingOutcome
Special educational provision
Outcome
Special educational provision
2:7 / Additional information you wish to provide Separate documents should not be attached
2:8 / Name of educational setting
Name of responsible person
Signed
Position held
Date