Community Learning & CommissioningNovember 2017

WORKING DRAFT

Post-16 request/contribution to an Education, Health and Care needs assessment

Request must be typed/word processed. Ensure that you have completed the EHCP pre-request checklist and read the Post-16 EHCP Application guidance provided before completion.

Please tick whether this form is:

A Request for an EHC Needs Assessment:

OR this is New or Updated Submission of Statutory Advice:

New

Updated

Date of Request: Date of updated submission:

1 – Young person’s details 1a Names/personal details

Young Person’s Legal surname: Forename(s)

:Surname also known as (if applicable):

Prefers to be known as:

Date of Birth: Gender:Male

Female

Address of Young Person(including postcode):

1b Current educational setting & care status

Setting Name:

Setting Address (& Postal Address if different)(including Postcode):

Setting Tel No:

Date of Admission to current Setting: Year group:

Is the young person placed in their chronological year? Yes No* * If No, in which

year?Child in Care? Is the Young Person subject to a care order or any other court order? Yes* No

* If Yes, Give details of the nature of the order and the name/contact address/telephone of the allocated Social Worker:

Do they have mental capacity in relation to EHCP decision making?

Yes No

If no, who is acting as the young person’s representative?If yes, does the Young Person want their parent/carer to Yes No

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support them in the EHCP decision making process?

1c Parent/carer/other details (names and addresses of ALL persons who hold parental responsibility under Children & Families Act 2014). Attach a separate sheet if necessary

Parent/carer 1 Parent/carer 2

Title: Title:

Family Name: Family Name:

Forename(s): Forename(s):

Address (including postcode):

Address(including postcode):

Telephone(Home):

Telephone(Home):

Telephone(Mob or Work):

Telephone(Mob or Work):

Email address: Email address:

Relationship Relationship

State any barriers to communication eg EAL, hearing impairment?

State any barriers to communication eg EAL, hearing impairment?

1d Language & religion of young person: Home Language(s):

Preferred Language:

Religion: Interpreter needed? Yes No

1e Other information relevant to young person’s needs:Has a Common Assessment Framework (CAF)/Early Support Plan been completed on this young person? Yes* No

* If Yes, name the keyworker and attach a copy of the CAF/Early Support Plan (having obtained parental agreement to forward the form):

CAF Attached?

Yes NoHas the young person had any support from Children’s Social Care in the past year? Yes* No

* If Yes, name the social worker involved for Children’s Social Care. Parents/carers will give permission to share information by signing section 8b at the end of this form.

Name/tel no of Social Worker:

Has the Young Person received short breaks during the past year? Yes No

Is the Young Person from a Services (Armed Forces) family? Yes No

Is the Young Person from a Traveller family? Yes No

From the end of Y11 onwards, a Young Person may wish to be fully involved in the process and be supported by a family member or friend who will, for example, receive correspondence on their behalf, fill in forms, attend meetings, make telephone calls and help make decisions.

If this is the case, is this person the Parent/Carers in Section 1c? Yes No*

* If NO, provide details (name/address/tel no/ email/ relationship) of ‘support person’ & attach this as an appended sheet –

Support Person Appended sheet?

Yes No

Does the young person want the ‘support person’ to receive correspondence Yes No

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on their behalf?

1f Views, interests, background and communicationYoung person’s views, interests, skills and hobbies:Include information on things that are important to the young person such as their favourite activities, hobbies they like doing and their overall general interests. Please also include the things that are important to them as they move into adulthood.

Young Person’s views and wishes on preparing for Adulthood:Education, employment and career / job ideas Being part of the community, family life and

friendships

Healthy living and positive wellbeing Independent living skills and housing

Young Person’s background/history including factual information about the family context if considered relevant: (include information that is relevant to the young person having SEND i.e delayed development/milestones, significant life or family events, early indicators of having a SEND, how their SEND impacted on school life and learning and any recent medical intervention or diagnosis etc)

How to communicate with and engage the Young Person (eg signing, PECS, ICT):

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2 Special Educational Needs, Learning and Attainment2a Attainment in main curriculum/post-16 learning areas Complete table to record qualifications/education awards already achieved and long-term attainment/ ability assessment using the National Curriculum/P Scales/GCSE Unsupported Levels and Post-16 baseline assessments. Provide age equivalent or standardised scores if you prefer.

Attach more detailed information if required regarding tracking, e.g. use of CASPA in special schools

Equivalent format can be provided as long as it shows the young person’s attainment over time

Qualification/award achieved

Date Achieved Grade Comments on attainment and future learning outcomes

Subject Area(Please include

subjects below as appropriate)

Previous Year Last Year Current Year Comments on current attainment

Date: Date: Date:

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2b Progress in Post-16 learning/curriculum areas Complete table to record long-term progress using the National Curriculum/P Scales/GCSE Unsupported Levels and Post-16 baseline assessments.

Equivalent format can be provided as long as it shows the Young Person’s Progress over time.

Date Assessed Subject/ Area of Learning Progress and future targetsInclude information that cannot be measured through standardised testing such as improvements in behaviour,

confidence, self-help etc

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2c Progress in Reading, Writing and Maths - Please complete the table below to detail areas of strength and need.

Strengths: Areas of need:

Reading

Writing

Maths

How the Young Person communicates and interacts with others. Clearly state what the young person’s strengths and needs/challenges are

How the young person feels and gets on with others. Clearly state what the young person’s strengths and needs/challenges are

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2.C. Broad Areas of need & support

Explain how the young person meets the threshold for an EHC needs assessment (please refer to the Bournemouth SEND guidance document 2017) with reference to the broad areas of need and support (include strengths and needs).

Cognition and Learning (add here any general information in addition to Section 2A Attainment & Progress tables above) – including accessing employment/higher education

What are the Young Person’s strengths?

What are the Young Person’s needs to learning and engaging in community participation?

How do the needs impact on the Young Person?

Communication and interactionincluding Friends, Relationships and Community Participation:

What are the Young Person’s strengths

What are the Young Person’s needs to learning and accessing employment/higher education?

How do the needs impact on the Young Person?

Social, emotional and mental health:

What are the Young Person’s strengths?

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What are the Young Person’s needs to learning?

How do the needs impact on the Young Person?

Sensory and/or Physical Needs:

What are the Young Person’s strengths?

What are the Young Person’s needs to learning?

How do the needs impact on the Young Person?

Independence and Self-Help - including Independent Living:

What are the Young Person’s strengths?

What are the Young Person’s needs?

How do the needs impact on the Young Person

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Provide a summary of why you believe “the child or young person has or may have special educational needs * such that “it may be necessary for special educational provision to be made for the child or young person in accordance with an EHC plan”. (CfA, 2014- subsection 8).

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2e Post-16 Education Setting Attendance

College/School/placement Name

(start with current placement then list previous schools in last 12 months)

Attendance from date: Attendance to date:

Attendance figures (include percentages) over the last three terms (including the present term).

ATTACH ATTENDANCE PRINTOUT*Autumn/Spring/Summer

Term 20……(*indicate relevant term)

*Autumn/Spring/Summer Term 20……

(*indicate relevant term)

*Autumn/Spring/Summer Term 20……

(*indicate relevant term)

Has the Young Person had any fixed term exclusions during the past year?

* If Yes, please list dates and reasons below:

YES* NO

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3 Health and Social Care needs3a Health needs

Physical and mental health, physical development and sensory needs. State how these needs impact on the child’s ability to learn, make progress and access the curriculum. Include evidence of medical diagnosis/conditions

Areas of strength:

Areas of need/challenges:

Other health needs Health conditions that do not impact on education or learning

Areas of strength:

Areas of need/challenges:

Self-help and skills for independence (related to health needs Such as medical conditions that impact on ability to dress, toilet, etc:

Areas of strength:

Areas of need/challenges:

3b Social Care or Early Help needs

Social Care needs (relating to SEN)Include information on Social Care or Early Help Services involved with the young person/family. Also, include any social care needs that the young person might have but not be receiving support for (such as accessing community activities, independent travel, Independent living etc).

Will there be any social care needs once the young person reaches 18 (if they are not of this age already)?

Areas of strength:

Areas of need/challenges

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4 Current provision (specific/quantified/costed) and measured impact

4a Post-16 SEN Support Attach the SEN SUPPORT PLANS (SSP)SSP Start Dates SSP Review Dates

Provide dates for the two most recent SEN Support Plan (SSP), or equivalent documents (ILP, IEP etc) and reviews. Attach copies ensuring they are signed, dated and there is evidence of reviewing outcomes. They should include detail of current provision and reviewed and how you are implementing the Graduated Approach (ASSESS, PLAN, DO, REVIEW) which is regularly reviewed to reflect the young person’s needs.

4b Current support arrangements, costed provision and observation of progress Settings have delegated funds to support pupils with additional needs, including those with SEN and disabilities. Please outline below any provision made from either delegated funds or Local Authority resources to support the young person’s needs.(please tick relevant funding option)

Additional Support funding

High Needs Funding

School’s delegated funds

Total amount of support currently funded = £

Give details of the targeted/specialist support provided for the young person including from setting or Local Authority, e.g. Outreach Service, Inclusion Services and Health provision. This is the support that is additional to and different from ordinary setting arrangements. Complete table below and indicate costs.

Support/Provision delivered

Desired outcomes sought from

provision

Strategies implemented

(1:1, groups, whole class)

Frequency, duration and by whom

Start Date-End/Review

date

Costs for this Young Person

(this information is essential)

Description of supporting evidence

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4c Progress in Response to ProvisionDescribe the overall impact of the support/provision provided. Has the provision supported the Young Person to make progress towards their outcomes? Why is additional support beyond SEN support now needed? Under paragraph 9.3 of the SEND Code of Practice 2015, in a very small minority of cases children or young people may demonstrate such significant difficulties that a school or other provider may consider it impossible or inappropriate to carry out its full chosen assessment procedure. For example, where its concerns may have led to a further diagnostic assessment or examination which shows the child or young person to have severe sensory impairment or other impairment which, without immediate specialist intervention beyond the capacity of the school or other provider, would lead to increased learning difficulties.

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4d How have Specialist Support Services or outside agency input been used to develop provision – graduated response?Examples of services/agencies are Educational Psychology Service, Hearing & Vision Support Service, Educational Welfare Service, Children’s Social Care, Therapists, CAMHS, Other.

Involved since (date)

Name of each professional involved/contact details

Service / Agency

Recommendations Action by school – targeted intervention

Outcome achieved/Impact for young person

Specialist training or professional development (PD) your setting/college/school has undertaken in order to support the child. How has this impacted on the Young Person’s progress?

Description of training/PD

Date undertaken Comments on how the training/PD has impacted on the young person’s progress

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5 Desired outcomes and aspirations

5a Briefly state the aspirations for the Young Person. These should be developed with the young person/parent carer and describe the long-term hopes/dreams/wishes of the young person.

State the desired outcomes(The expected benefit or difference made to the Young Person as a result of a support being put in place) These should be developed with the Young Person/Parent Carer. (See Bournemouth SEND EHCP guidance for help with developing outcomes)

Preparing for Employment/Higher Education Independent Living

Friends, Relationships and Community Participation Good Health

State any shorter-term targets that have been discussed with the Young Person/Parent Carer.

How have you involved the Young Person/Parent Carer to develop SEN support and complete this EHCP application.

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6 Ranking of identified primary and other needsSee Code of Practice 2015, along with the Bournemouth Special Educational Needs SEND Guidance

6a Indicate the PRIMARY NEED with a 1 and, if more than one need, please rank the others in terms of significance (you should discuss this with your Educational Psychologist):

Need Ranking Please indicate below any medically diagnosed conditions

eg ADD, ADHD, Cystic Fibrosis, Downs, MS, MD, Epilepsy, etc

Communication and interaction:

Autism (including Asperger’s syndrome) (ASD)

Speech, Language & Communication Difficulties (SLCN)

Cognition and learning:

Moderate Learning Difficulties (MLD)

Severe Learning Difficulties (SLD)

Specific Learning Difficulties (SpLD)

Profound and Multiple Learning Difficulties (PMLD)

Social, emotional and mental health difficulties:

Social, emotional and mental health difficulties

Sensory and/or physical needs:

Physical Difficulty (PD)

Hearing Impairment (HI)

Visual Impairment (VI)

Multi-Sensory Impairment (VI)

7 Checklist of essential documents attached

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Document RequiredDocument Attached?

YES

Document Attached?If no, indicate why document

is missing

7a

The young person’s One Page Profile or similar document

Young Person’s View – the child/young person should be encouraged to contribute. This may be done either through the setting or via the parent in a format appropriate to the young person’s needs – either a One Page Profile or similar document:

7b

The Parent/Carer’s ‘My Child, My Story’ or similar document

the parent(s)/carers should be encouraged to submit a written contribution detailing their perception of their child’s difficulties and needs. Copies of a leaflet ‘My Child, My Story’ can be obtained from the SEN Team to help them do this. The SEND Information Advice and Support Service (SENDIAS) will also help parents to write their contribution.

7c2 most recent SEN Support/IEP/ILP plans and Reviews at SEN Support (or the provision map with evidence of impact)

7dCopies of assessment information, e.g. reports or letters from SENCOs, test results

7e

Evidence that the Educational Psychologist has been involved in planning the interventions and reviewing progress (must be within the last six months), i.e. (Joint Action Plan and Joint Review forms)

7f

Reports or Records of Involvement from other Local Authority Inclusion Services, Children’s Social Care, Outreach and from Health (e.g. Speech & Language Therapist (SaLT); Physiotherapist, Occupational Therapist, Paediatrician, Psychiatrist)

7g Pastoral support plans, where appropriate

7hBehaviour Management Plan/Positive Handling Plan, where appropriate

7i Risk Assessment, where applicable

8 – Authorisations8a Headteacher/Manager/Principal

I confirm that, having followed the procedures outlined in the Code of Practice, the setting is making this request for, or contributing Statutory Advice to, an EHC Needs Assessment.

I confirm that the Educational Psychologist is aware of this request and has been involved in supporting the

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setting to meet this child’s/young person’s needs.

I have enclosed evidence of Consultations, Records of Involvement from relevant professionals and have gained parental consent to share these along with evidence of graduated response.

Headteacher/ Manager / Principal:

Name (BLOCK CAPITALS): Signature: Date:

8b Parent(s)/carer(s)

I consent to this information being used as a request for, or a contribution to, an EHC Needs Assessment. If the request is agreed, I consent to appropriate agencies including Education Services, the Health Service and Social Care, sharing and discussing relevant information relating to my child.

I confirm that I consent to psychological and medical reports being obtained for my child if the process goes ahead.

Data Protection At 1998 The Data Controller for Bournemouth Borough Council is Head of IT Services. This information is being collected for the purpose of administering referrals, but may be used for the wider purpose(s) of the provision of education services. When you complete this document, you are providing your consent for the Council to hold and use this personal information for these purposes. The information you provide may be disclosed to: other internal directorates, those with parental responsibility, healthcare, education establishments, other LAs, the DCSF, the diocesan boards, courts and tribunals.

Name(s) (BLOCK CAPITALS) and relationship to child/young person:

Signature: Date:

Young Person

Parent(s)/Carer(s)

This form was developed using a Pan Dorset approach. Information provided may be processed electronically and used for administrative, audit and quality

assurance purposes.

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9 Sending this form9a How and where to send this form

Please send your fully completed form and attachments as follows:

1. Hard copy via post/internal courier to The SEN Team, Floor E3, Town Hall, Bourne Avenue, Bournemouth, BH2 6DY

2. Via email - YOU MUST USE SECURE EMAIL as follows:

a. You may send this form electronically, by attaching to email and also scanning the Authorisation pages and attachments. Please put in the Subject Line either: Request for an EHC Needs Assessment OR Submission of Statutory Advice

b. If sending from a bournemouth.gov.uk email address, simply send to: SENTeam@bournemouth.gov.uk. This will automatically be secure.

c. If sending from other email addresses, you will need to send via a Clearswift account – a secure website portal where you set up an account with your email address and password. If you don’t have a Clearswift account set up with us, please call the SEN Team on 01202 456162.

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