Classification: OFFICIAL
School Information for Statutory Education Health Care Assessment
Current School / Setting
School /Setting *Start date / Dd/mm/yyyy / End date / Dd/mm/yyyy / Dual Placement / Yes / No / put details below #
School /Setting #
Start date / Dd/mm/yyyy / End date / Dd/mm/yyyy
Previous School (s)/ Setting(s)
School /SettingStart date / Dd/mm/yyyy / End date / Dd/mm/yyyy / Dual Placement / Yes / No / put details below #
School /Setting #
Start date / Dd/mm/yyyy / End date / Dd/mm/yyyy
School /Setting
Start date / Dd/mm/yyyy / End date / Dd/mm/yyyy / Dual Placement / Yes / No / put details below #
School /Setting #
Start date / Dd/mm/yyyy / End date / Dd/mm/yyyy
School /Setting
Start date / Dd/mm/yyyy / End date / Dd/mm/yyyy / Dual Placement / Yes / No / put details below #
School /Setting #
Start date / Dd/mm/yyyy / End date / Dd/mm/yyyy
Young Person's Details
First Name(s) * / Surname *Home Address*
Post code*
Date of Birth * / Gender
Ethnicity * / Religion
NHS number / Education UPN*
Care Order? * / Home Language *
Has an Early Help Assessment (CAF) been carried out or underway* / Yes / No / Date of CAF / Dd/mm./yyy
Name and designation of person completing this form*
Parent(s) or Person Responsible Details
Details of parent(s) or person responsibleFirst Name(s) * / Surname *
Home Address*
Post code
Telephone * / Mobile
Relationship * / Home language*
Any special arrangements?
First Name(s) / Surname
Home Address
Post code
Telephone / Mobile
Relationship / Home language
Any special arrangements?
Other family members at home
Name(s) * / Relationship to child *Example:
Say : Refer to EHC Plan assessment form if you filled in that form as you have already given this information there
Chronology of School Support * **
Please give an overview of the support given by school during time placed with you.
Please see guidance for examples of how you may show this.
Example:Since (DATE) when CHILD started nursery, additional adult support has been provided
(Include dates of the interventions you and other professionals have implemented).
· Nursery staff have worked closely with parents to help settle CHILD into nursery and in agreement with parents have involved outside agencies.
· Nursery has implemented differentiated activities with additional adult help and resources to support and include CHILD in everyday and specific activities.
· DATE– Referral made followed by Initial visit from Speech Therapy - nursery implemented targets and recommendations set by speech therapist. Their involvement is on-going and includes half termly reviews.
· DATE– Nursery provided report to medical professionals as requested to contribute to a diagnostic assessment.
· DATE – Referral made followed by Initial visit from Early Intervention Team STePS- on-going monthly visits to review CHILDs progress and to support nursery staff to meet CHILD's needs.
· DATE- Nursery have attended/co-ordinated meetings with parents and other professionals to plan and review CHILD’’s progress and needs.
· DATE- Implemented Physiotherapy targets/recommendations as requested.
· DATE- Implemented formalised target plans
Continuation of support: Note here the on-going support you provide on a daily basis
If you allocate specific time slots each day for particular activities such as physiotherapy /speech therapy practice / medical care, note this down.
Example:
Adult time allocated daily to carry out specific speech and language programme - 10 minutes a day plus supporting CHILD throughout the day in using Picture Exchange Communication system within nursery environment.
Adult time allocated daily to carry out physiotherapy recommendations- 5 minute exercises every half an hour
Adult time allocated several times daily to support CHILD to develop his play and learning skills
Adult time allocated several times daily to support CHILD to develop his self help/ personal skills including toileting and feeding and medical needs.
Adult time allocated several times daily to facilitate and support CHILD in his social interaction and communication with peers
Throughout the day close adult observation to
Oversee and monitor CHILD's general engagement in activities
Ensure CHILD’S emotional well- being
Monitor CHILD’S medical needs
Model and promote positive behaviours
Academic achievements and progress * **
Please give evidence of the current levels the child / young person is working at.
You may wish to record using age appropriate scored / P scales / .....
Note here the type of assessment you use for recording development and progress,this could be the EYFS assessment or the Teaching Talking Profiles. Include copies of up to date assessments with your referral forms.
Example:
CHILD is functioning approximately at these levels in the following areas of development according to assessments carried out using the EYFS assessment model
Physical - around 2 year old level
Speech, Language and communication –8-20 months
Emotional and social development- 8-20 months
Play and Learning – 8-20 months – higher in some aspects
Self-care and independence – 8-20 months
The progress CHILD has made to date has been due to the intense support programme put in place at nursery under the guidance of health and educational professionals.
Comment to signpost to attached documents sent in with request
Example:
Please refer to attached development profile/EYFS Tracker
Pupil / Young Person's area of SEN need: *
Please indicate with a 1 the pupil / young person's primary area of need, then with a 2, 3 or 4 any additional areas of need
Communication and InteractionCognition and Learning
Social, Emotional and Mental Health Difficulties
Sensory and / or Physical Needs
Nature and extent of need: *
Note here to refer to other documents to save repeating more in depth information if you have already given it in the EHC assessment request form. If you have not made the request yourself you will need to provide more detailed information on the child’s needs in this sectionExample:
Speech, Language, Communication: CHILD has difficulty with receptive and expressive skills, listening and attention.
Physical Development: CHILD has gross motor skills delay, low muscle tone, hypermobility in most joints and immature co-ordination.
Emotional and Social development: CHILD has social communication and interaction difficulties. He can be passive and anxious and very dependent on an adult supporting his emotional stability.
Learning: CHILD has low level play skills. He needs an adult to support and facilitate his involvement and to demonstrate play.
More information is detailed in EHC Plan assessment request
Action taken to meet needs and impact of action: *
You could note here refer to the Chronology of support information you have given aboveExample:
Impact of action;
CHILD is starting to learn how to position hands to throw/catch a ball
CHILD is starting to jump lifting one foot at a time off the ground
CHILD is starting to use two word vocabulary and talk to self in play
CHILD is starting to gain a familiar adult's attention by touching them
CHILD is becoming consistent in making a choice between two objects offered together
CHILD is starting to become more confident around other children and with adult support will engage in shared activity with them
CHILD is starting to actively engage in self-help tasks such as moving trousers up/down at toilet time.
What works for the pupil / young person? *
If you have already given this information in the EHC assessment request form, note that down here and refer them to it. If you haven’t given this information you need to write here what strategies and ways of working you implement such as; the ways you and the child communicate with each other, what helps to motivate the child, how you try to settle the child or manage their behaviour – (is this always effective? if you have to try a combination of techniques note this down) Note down anything that you have to change in the environment to help the child. Say what helps them to learn and achieve tasks more easily.Example: Understanding and Communication
Objects of Reference
‘First Then’ directive/visual strip
Photographs of activities/objects
Visual timetable
Choose Board
Picture Exchange Communication System (PEC’s)
Gesture/ Signs
When giving group instruction follow up with one to one instruction for child.
Example: Environmental changes
Noise level low
Small group activities including some 1-1 allocated time with adult to work on targeted activities to help with listening and attention skills.
Provide enclosed quiet area for child to retreat to if needed.
Positioning of child at group activity times to help with their visual/auditory
Providing identified ‘spot’ for child to know where they sit
Example: Learning and Self Help skills
Modelling of tasks
Hand over hand support to help child to position their hands/body to achieve successful task
Giving child time to process information and respond
Please include three sets of target setting, two of which must be reviewed.
Indicate the dates of these below. *
Parents should have been involved in this process – please include meeting records which evidence this.
These could be a combination of Educational targets, Speech Therapy plans, Physiotherapy plans or Behaviour plans if you haven’t worked through two or more sets of targets.
Accompany these with the noted review comments and copies of SEND target and Review Meeting minutes from the meetings held with parents.
Set 1 of Target Setting / Date: / Dd/mm/yyyy / Meeting records included / Note Yes or NoDetails / Example: Educational targets and review of targets
Set 2 of Target Setting / Date: / Dd/mm/yyyy / Meeting records included
Details / Example: Speech Therapy plan review and new targets
Set 3 of Target Setting / Date: / Dd/mm/yyyy / Meeting records included
Details / Example: Physiotherapy plan
Views of the Pupil / Young Person * Staff signature and date
Pupil views form is attached / included with request / Tick and sign as appropriateWe have been unable to collect the child's views
Pupil observation sheet attached / included with request
Other – please describe
Views of the Parent(s) / Responsible Person * Staff signature and date
School have supported parent(s) / Responsible person to complete their information sheet / Tick and sign as appropriateParents have sent back their request independently
Parent(s) / Responsible person have not shared their views with school
Other – please describe
Please tell us about all the people who work with the child *
Education / If you have already given this information in the EHC Plan request form refer to thatName / Designation (what role they play) / Early Intervention Practitioner
Setting
Phone number / Email
Name / Example: / Designation (what role they play) / Educational Psychologist
Setting / STePS
Phone number / Email
Health / Example:
Name / Designation (what role they play) / Speech Therapist
Setting / Speech Therapy Service
Phone number / Email
Name / Example: / Designation (what role they play) / Health Visitor
Setting / Health Team
Phone number / Email
Name / Example: / Designation (what role they play) / Physiotherapist
Setting / Physiotherapy Team
Phone number / Email
Social Care
Name / Designation (what role they play)
Setting
Phone number / Email
Name / Designation (what role they play)
Setting
Phone number / Email
Other
Name / Designation (what role they play)
Setting
Phone number / Email
Name / Designation (what role they play)
Setting
Phone number / Email
Signed (please print name as well as signature)* / Date: *
All information provided will be treated in confidence, in accordance with the Data Protection Act 1998 and used for the purpose of assessing your child’s special educational needs. The information provided may be shared with other Professionals involved in the assessment process who will use it as part of the assessment process.
Classification: OFFICIAL
Version 1 – 06/10/2014 *means you must type/write in this box
**Please use additional paper if you need more space
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