Professional EHC Needs Assessment Request Form

Professional EHC Needs Assessment Request Form

Guidance

This information is sought in accordance with the Children and Families Act 2014. This report will be used by the school/ college to help develop a graduated approach for a young person who has special educational needs. It can also be used to support a request for Education, Health and Care needs assessment to the Local Authority.

If you cannot enter any information in a section leave it blank and continue on with the rest of the form. You may also attach any relevant reports or addendums in lieu of or in addition to completing this form.

This form is intended to be filled out electronically, if you require a hard copy request form please contact the relevant locality casework team using the details found at the end of this request pack.

Template version 2.0 - updated 07.03.2016

Personal Details

Full Name: / Educational Setting:
Date of Birth: / Age / Gender / Type: / Please Select… /
Child's Address: / Ethnicity / Please Select… /
First Language
Do any of the following apply?
(select from the drop down boxes) / Looked After / TAC / Child Protection / Families Working Together / ESCO / Child in Need / Free School Meals
Please Select… / Please Select… / Please Select… / Please Select… / Please Select… / Please Select… / Please Select…
Parent/Carer Name: / 2nd Parent/Carer Name:
Relationship: / Relationship:
Parents Address (if different) / Parents Address (if different)
Who has parental responsibility?
Phone Numbers / Phone Numbers
Email Address / Email Address
Preferred Method of Contact / Preferred Method of Contact
Who is making the request? / Name / Position / Title

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SECTION A: Pen Picture

In no more than 250 words please briefly describe the child's life so far. You may wish to complete this box after you have filled out the rest of the form

Please Note: The text box is a fixed size due to the word limit, entering anymore text than can fit in the frame above will result in the text being hidden from view.

SECTION B: Relevant Background

The following information should be included in this section:

What has your involvement been with the child/young person? Please indicate the nature of involvement and the dates that the involvement took place.
Relevant early history of the child/young person at home:
Relevant early history of the child/young person at school/college:

SECTION B:Identified Needs

The identified special educational needs – What do you consider are the areas of difficulties which impedes access to the curriculum / provision. You may wish to complete more than one section.

Please include any details of child / young person's needs and/or any diagnoses made.

Barriers to learning / What impact does this have on learning and development? What level of differentiation is required?
Communication and Interaction
Cognition and Learning
Social Emotional and Mental Health
Sensory and/or Physical Needs (including Health needs that impact on access to learning)

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Are there any additional significant factors – if the answer is yes please attach copies of relevant information/advice

Include where relevant both past and present circumstances that are relevant to the request.

Health
(Not already described above in Section B) / YES/NO
Attendance
(Eg, the involvement of an EWO / Attendance Officer ) / YES/NO
Home Circumstances
(Eg. Where relevant, reference to the fact that the request is for: a child of service personnel; a young carer; a traveller child or is adopted.) / YES/NO
Social Care / Family Support
(Eg. TAC, ESCO, CiN, CP, LAC) / YES/NO
Other: (please provide details) / YES/NO

SECTION C: Attainment

Attainment/Progress details – complete the table below to reflect assessments undertaken in the subject areas relevant to the child/young person.

Date Assessed / Year Group / Age / Type of Assessment

Current arrangements in place: outline the specific interventions that the child/young person is receiving and how these arrangements are being monitored

Type of provision: / Objective of Provision / Frequency & Duration / Delivered by / Start
Date / Review
Date / Outcomes: (Achieved, partially Met, Not Met)

Qualitative Progress / Observed Progress

Please include information such as improvements in behaviour, confidence, self-help / care etc.

Date / Observations

Formal Assessments –

Having outlined the interventions currently in place the professional should now describe the assessment process and the tools and techniques deployed to inform findings.

Please provide details on the assessment you have used:Please indicate those that are standardised

What test has been used and why?
Explain the test and what it will tell us
Describe the test circumstances/length of test/where undertaken
Explain the findings of assessments
Explain the implications for learning and deployment – where will the child / young person have difficulties

Name of Test / Date / Age / Benchmark (Year Group / Raw Score) / Standardised Score / Percentile / Age Equivalent

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SECTION D: Young Person's Views

What is important to me?
What I like to do / What am I good at?
How do I communicate?
What do I need help with?
These views were gathered / recorded by:

SECTION E:Parent's / Legal Guardian's Views

Where relevant and consent has been given by the young person if they are over 16 years of age, please ensure that the parent's and / or legal guardian's views are sought and recorded in the table below.

You may wish to seek views and then fill out table below electronically, if you do so please ensure that parents / legal guardians have had the opportunity to confirm that what has been written is a true and accurate picture.

What's working well? / What's not working well?
(Eg, Both in school/ college and out) / What would you like to happen?
(Eg. The support you believe is required and the educational outcomes that you believe are not currently being met)

SECTION F: Outcomes (Social Care Use Only)

Set out here a list of the outcomes sought for the child/young person

Outcomes Sought / Timescales to achieve

SECTION G: Provision (Social Care Only)

This section sets out any social care provision reasonably required by the learning difficulties or disabilities which would result in the child/young person having SEN and/or any provision which must be made resulting from section 2 of the Chronically Sick and Disabled Persons Act 1970.

Type of Provision/Resources / Objective of Provision/Resources / Frequency & Duration / Delivered By / Outcome Sought / Cost

SECTION HRecommendations

What additional support do you feel is required over and above that already provided?

Objective of Provision / Frequency &
Duration / Delivered by / Resources /Materials /Differentiation /Training / Outcome Sought

SECTION I: Documentation to support request

Please list details of attached reports/evidence from appropriate services. Include only reports which are relevant to the current request and the child/ young person's identified needs. You are only required to submit evidence where evidence has already been sought and/or given.

Please note the involvement of specialists is essential to help evidence that an informed assess, plan, do, review approach has taken place. Please see Paragraphs 6.58-6.62 of the SEND Code of Practice 2015.

EDUCATION
Service Provided By: (Name & Role) / Date of report/ consultation record/ document relevant to need. / Name of professional (where relevant) / Brief description of involvement
(including a brief description of any evidence attached to the request)
1. Educational Psychology consultation records or reports (where available). This is important to show that the assessment of need, provision to meet need and review of the same has been informed by an Educational Psychologist.
2. Working Together Team Discussion Record (where relevant) - previously known as Social Communication Outreach Service,to show that the assessment of need, provision to meet need and review of the same has been informed by the Working Together Team.
3. Sensory professional report or documentation – eg. Sensory Education & Support Team (SEST) for pupils whose HI/VI/MSI is affecting access to the curriculum.
4. Behavioural professional report where the pupil’s behaviours are a predominant need e.g. TLC Pathways or other independent provider together with a risk assessment where appropriate is included
5. Specialist Teachers
Such as the Specialist Teaching Team (STT) or other independent provider
6. Early Years Serviceas appropriate where significant need has been identified before statutory school age.
7. Youth Offending Service
8. Other Specialist Services
HEALTH
Service Provided By: (Name & Role) / Date of report/ consultation record/ document relevant to need. / Name of professional (where relevant) / Brief description of involvement
(including a brief description of any evidence attached to the request)
1. Speech and Language Therapist report or other evidenced language input (Elklan) where language is regarded to be a significant concern/need. This is important to show that the assessment of need, provision to meet need and review of the same, has been informed by the Speech and Language Therapy Service or other relevant language specialist.
2. Occupational TherapistDocumentation where motor/physical difficulties are regarded to be a significant concern/need. This will show that the assessment of need, provision to meet need and review of the same has been informed by an Occupational Therapist
3. Physiotherapist documentation where motor/physical difficulties are regarded to be a significant concern/need. This will show that the assessment of need, provision to meet need and review of the same has been informed by a Physiotherapist.
4. Paediatrician or other expert health practitioner documentation where general health/ medical issues are a significant concern/need and, where relevant a Health Care Plan.
5. CAMHS (Child and Adolescent Mental Health Service)
6. 0 – 19 Team (Previously known as Health Visitors)
7. Other Specialist Services
SOCIAL CARE
Service Provided By: (Name & Role) / Date of report/ consultation record/ document relevant to need. / Name of professional (where relevant) / Brief description of involvement
(including a brief description of any evidence attached to the request)
1. Where appropriate and relevant, a summary of social care needs, interventions and recommendations provided by Social Careprofessionals, including those provided in the home and community. This could be a record of involvement by, for example, an ESCO worker or TAC or Social Worker.
2.Multi agency meeting minutes
Please include minutes from multi agency meetings such as TAC, Looked After Child, Child in Need, Child Protection meetings.
Please ensure that you have obtained consent from the person holding parental responsibility before sharing sensitive information
3.Electronic Personal Education Plans
4. Prevent Strategy
5. Other Specialist Services
(such as those relating to counselling / gender issues and identity)

SECTION J: Exceptional Circumstances

If there are any exceptional circumstances as defined in the Code of Practice Paragraph 9.3 please describe them below

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SECTION K: Consent to Proceed

Please Note: You may wish to print this page separately in order to get a signature. If you are sending the request in electronically please scan in the signed consent form and send along with the request. This will speed up the processing of the request.

Name of Child / Young Person:

Date of Birth:

As part of the EHC needs assessment the Local Authority will need to request information relevant to the assessment from our partner agencies. Could you please ensure parents / legal guardians are aware of this requirement and have read the LCC SEND Data Sharing Agreement before submitting the request.

Please indicate using the statements below if parents / legal guardians are happy for the Local Authority to request and share information relevant to the EHC needs assessment.

If a young person is over 16 years then the Local Authority will need consent from them directly in line with the Mental Capacity Act 2005, rather than from their parent / legal guardian.

N.B. Without consent of the parent / legal guardian / young person, the assessment process cannot proceed.

Please indicate in the boxes below whether you do or do not agree with each statement

I agree for the Local Authority to request and share information with other agencies with regards to the EHC assessment process under the Children & Families Act 2014.
I do not agree for information to be shared with the Local Authority as part of the EHC needs assessment process under the Children & Families Act 2014
If an assessment is agreed and an EHC Plan is issued the Local Authority requires your permission to enable the plan to be shared with relevant professionals
I DO agree for the Local Authority to share any EHC Plan or feedback produced as part of the EHC needs assessment to partner agencies who have been involved with the assessment.
I DO NOT agree for the Local Authority to share any EHC Plan or feedback produced as part of the EHC needs assessment to partner agencies who have been involved with the assessment.

Signed ______Date ______

Parent(s)/ Person(s) Responsible / Young Person (Please delete as appropriate)

To Be Completed by the person submitting this request:

Signature: / Name:
Job Roll: / Date:
Contact Tel Number: / Contact Email Address

Please return this form, together with any reports to the relevant locality team responsible for your area based on young person's home address not the educational setting:

East Lindsey:

Lincoln & West Lindsey:

North Kesteven & South Kesteven:

Boston & South Holland:

A cautionary note:

When submitting information to these locality email addresses, we cannot guarantee the information you provide will be sent to us 'securely'. This depends on the email service you use.

If you have any concerns regarding this matter please contact us on telephone 01522 553332 before emailing, to enable us to communicate via LCC secure mail.

Or by post to: SEND Team, Lincolnshire County Council, 9/11 The Avenue, Lincoln, LN1 1PA

Office Use

Date Received: / Response due by:
Officer: / Panel Date:

Template version 2.0 - updated 07.03.2016