Parent/Carer Request for an Education, Health and Care Assessment
Please fill in as much of the following sections as you can. There is a section for your child to complete, if he or she
wants to, at the end of this form.
About your Child / Young Person:
Child/Young Person’s name
Child/Young Person’s Address
Date of birth
Religion
Name of education setting
Address of education setting
Ethnicity
Languages spoken at home
Is an interpreter needed?
Name of GP
Address of GP
Age :
Year group:
About you as primary carer
Your name
Your Address
Relationship to the child/ young person
Religion
Ethnicity
Languages spoken at home
Is an interpreter needed?
Contact number
Email address
About you as another carer
Your name
Your Address
Relationship to the child/ young person
Religion
Ethnicity
Languages spoken at home
Is an interpreter needed?
Contact number
Email address
YOUR VIEWS
Please tell us about your child’s difficulties and the support that might help. The more information you give us, the
easier it is for us to make a decision. If your child is at nursery, school, college (or another educational setting) it is
very useful to ask them to work with you to complete this request form. If you can’t write this with the setting, we
will ask them for information.
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Background
What services, if any, have been involved with your child in the last 12 months? If you have a recent report from
them, it is useful to send that in too. Please tell us if you have a social worker, and what his/her name is.
Name
Service
Contact Details
Description of Support/Services
Provided
Is a report
attached?
If your child is receiving support from the health service either at home or in school, you can tell us more about it
here (This may include support from your GP, Specialist Therapist, Paediatrician and Psychiatrist. Please provide
details of the support provided)
Please tell us where you child/young person has been educated in the last five years:
Educational Setting Name
Year
Group
Start
Date
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End
Date
Reason for Leaving
What is happening now?
What are the difficulties that your child is having? The questions below are to help you describe your child’s special
educational needs.
Does your child have
difficulty with speech,
language and/or
communication? If so,
what are they?
Does your child have
learning difficulties? If
so, what are they?
Does your child have
difficulty managing
his/her emotions or
relationships? If so,
can you describe this?
Does he or she have
sensory (seeing,
hearing etc) or
physical needs? If so,
what are they?
Does he or she any
other health needs? If
so, what are they?
Are there any other
areas of need? If so,
what are they?
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How have things changed (got better or worse) over the last year?
At home?
At school / in their education setting?
What’s going well for your child at the moment?
At home?
At school / in their education setting?
What’s not going well for your child at the moment?
At home?
At school / in their education setting?
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What’s making a difference?
At home? (If your family is receiving support from Family or Social Services, tell us what it is and how well it’s
working.)
At school / in their education setting? (If your child is receiving support in school/setting, tell us what it is and how
well it’s working.)
How would you like things to be different for your child over the next year?
At home?
At school / in their education setting?
What support do you think might make more or a better difference?
At home?
At school / in their education setting?
Signature:
Date:
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Parent/Carer Request for an Education, Health and Care Assessment
CHILD/YOUNG PERSON’S VIEWS
Please tell us about yourself if you would like to.
About Me
What I like doing and what I want to do
What is important to me and why
Why I think and Education, Health and Care Plan could be helpful to me.
Signature:
Date:
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DO YOU NEED HELP TO COMPLETE THIS FORM?
Tri-borough Special Educational Needs Casework and Commissioning Team
The SEN team will be happy to answer any questions that you may have about the completion of this form. Contact
them on:
Tel: 020 7361 3311
Email: SEN@rbkc.gov.uk
If you would like the Local Authority to put you in touch with an Independent Facilitator, please tick here:
Please return this form, together with any reports to:
Tri-borough SEN Casework and Commissioning Team
Royal Borough of Kensington and Chelsea
Kensington Town Hall, Hornton Street
London, W8 7NX
Office Use:
Date Received:
Response due by:
Officer:
Panel Date:
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