Child/Young Person Support Request Form
V4 (To be completed by the requesting school/ setting.)
Name and type of
school/setting:
Form completed by:
Role:
Contact Tel:
Contact email:
Headteacher:
Name of pupil
Date of birth
Gender
Ethnicity
Year Group
SEN Status:
SEN Support
Statement/EHCP
Nature of need
Attainment levels:
EYFS
NC/P-Scales
SATs
Reading Age (inc.
test used)
Support
requested
Medical information
Curriculum access/differentiation
Involvement of
other agencies
Support with assessment and planning
Please tick
against the menu
of services
Challenging behaviour/behaviour
management
Induction/transition
Agency
Date
SLT
Please tick and
indicate date of last
input
EP
EMS
Communication
Physio
Intervention advice
OT
Speech, Language & Communication/
Autistic Spectrum Conditions
Health Visitor/ School
Nurse
Developing social and emotional skills
CAMHS
Developing functional skills
CAMHS LD
Sex and Relationship Education
Social Worker
Adaptive technology and/or ICT support
MABS
Access to resource or specialist equipment
STA
ICT support/ alternative forms of recording
Early Years Panel
Positive people handling risk
assessments/training
Other (please detail)
Anxious/withdrawn behaviour
CAF in place?
Yes
No
Other (please detail)
If yes, Lead Professional information:
Name:
Role:
Contact info:
Child/Young Person Support Request Form
V4 (To be completed by the requesting school/ setting.)
Please complete information requested overleaf.
Is the child/young person
accommodated (under Section
20 of the Children’s Act)?
Is the child/young person subject to
a care order?
Is the child/young person subject
to a child protection plan?
Profile of needs
(Please use the attached guidance when completing the profile of need.)
Level from SEN Profile
of Need (0 to 4)
Physical & Medical
Hearing
Vision
Speech & Language
Emotional Development
Cognitive Ability
Social Development
Dispositions and Attitudes
Specific Learning Difficulties
Parent’s/Carer’s Comments
Please outline your view of your child’s / young person’s strengths and the specific concerns which have
prompted this request for support?
What changes do you hope that the intervention of the PSENSP will bring about?
Any additional comments you would like to make in support of this request?
Child/Young Person Support Request Form
V4 (To be completed by the requesting school/ setting.)
Child’s/Young Person’s Comments
What is going well for you at the moment?
What would you like to change?
Parental consent
The Portsmouth SEN Support Partnership works closely with professionals in Education, Health and
Children’s Services. In order that we can provide the most appropriate response to improve outcomes for
your child we need to gather and share information with others who are supporting you or you have had
previous contact with. Your signature(s) gives consent for us to speak to other agencies named on this form.
You can withdraw your consent at any time. If you have any concerns regarding the sharing of personal
information about you or your family please discuss this with the person completing the form with you.
I have understood the completed version of this form and agree to request support from the Portsmouth SEN
Support Partnership.
Signature of Parent / Carer……………………………
Please print name……………………………….
Signature of Parent / Carer…………………..………..
Please print name……………………………….
Date…………………………………………………
This form must be signed by the parent(s) before any work with the child can be undertaken by the
Portsmouth SEN Support Partnership.
Support requested by and authorised
by (Head teacher/SLT/SENCO)
Signed:
Role:
Date:
Please attach any recent and relevant information such as IEPs, Assessments and Reports.
Please return to:
PSENSP, Mary Rose Academy, Gisors Road, Portsmouth, PO4 8GT
psensp@maryroseacademy.info
Special Education Needs: Profile of Need
Needs profile 0
Needs profile 1
Shows limited fine and/or gross coordination skills.
Physical
Health /
Medical
No needs in this area;
physical development and
general health within normal
levels.
Independently mobile without the use
of aids, etc., but requires assistance
for some
routines/self-care skills.
May need support with administration
of regular medication in setting.
Needs profile 2
Needs some help or requires
adjustments to be made to
learning environment to support fine
and/or gross motor skills. Limited
independence.
Hearing
Hearing within normal limits.
Can hear clear voice without
amplification
Mild impairment
Vision
Speech and
Language
(green
columns
relate to
school age
pupils)
Vision within normal range,
including when corrected by
glasses 6/6-6/12
Mild
language
delay
Language &
communication
skills within
expected
range
or mild delay
Pupil can at best
participate with a simple
movement in special
situations.
Needs access to wheelchair for
movement either independent with
chair or adult supported. Can sit
when supported.
Mobile with the use of walking aids.
Requires constant adult supervision
to ensure health and safety.
Severe limitations in head
and trunk control and
require
extensive assisted
technology and physical
assistance.
Severe hearing loss needs aids
e.g. radio aids/ sound filed
systems for curriculum access
Very limited functional
hearing for speech
despite aids
May use signing as aid to
communication
Signing indicated as
appropriate
/ Signing as first language
Moderate hearing loss, uses postaural aids, non-verbal cues
for communication
Mild bilateral field loss or adapted to
monocular vision. Navigates safely
Moderate impairment, partial sight
e.g. needs enlarged print, minimum
N14
Wears patch 1-2 hours daily
Moderate bilateral field loss.
Colour blind
Has safe navigable vision in familiar
areas.
Moderate / severe delay
in expressive or
receptive
language or
Mild language disorder
or
mild/moderate speech
sound
disorder/delay
of any severity
(without attention/listeni
ng difficulties)
Needs continuous help with fine
and/or gross motor skills. Even
with adaptations to the learning
environment limited participation.
Needs profile 4
Needs assistance on stairs, etc.
Not capable of running and jumping.
Can sit on their own or require at
most limited external support.
Needs daily adult support with selfcare.
Mild hearing loss (e.g.
conductive or unilateral hearing loss)
Needs profile 3
Moderate
delay in
Pupil has severe
expressive
language delay or
and / or
moderate language
receptive
disorder Or a
language
severe speech
and or mild
sound disorder
disorder in
(with attention/listeni ng
speech
difficulties)
sound
production
Severe
delay in
expressive
and / or
receptive
language
and /
or
moderate
language /
speech
sound
disorder
Severe impairment, partial sight,
e.g. needs access to enlarged
print N18+, most work modified
Minimal or no sight (e.g.
Braille) to access the
curriculum.
Has limited navigable vision
Needs adult support for
safe navigation.
Severe language disorder or
diagnosed dyspraxia
Severely limited language
skills, uses alternative
communication
systems to make
needs/choices
known
Needs profile 0
Emotional
Development
Cognitive
Ability (green
columns
relate to
school age
pupils)
Social
Development
(green
columns
relate to
school age
pupils)
No significant needs in this area.
Cognitive abilities
above or
Cognitive abilities
within broad
above
average
or within broad
levels or with
average levels.
a mild delay.
Quotient
scores on
Working above,
standardised
within or slightly
assessments
below the age
85+
expectations of
EYFS.
No significant needs in this area.
Needs profile 1
Some difficulty forming healthy
emotional attachments.
Needs profile 2
Difficulty in forming healthy emotional
attachments.
Fairly often shows lack of or
Lacks self-confidence and selfesteem. inappropriate emotions and interaction
with others.
Some learning
difficulties,
shows some
difficulties with
conceptual
understanding,
(e.g. colours,
shapes),
symbolic,
imaginative & make
believe play.
Some
evidence of
child working below
age
appropriate
achievement within
EYFS.
Cognitive
assessment
below the 15th
centile or a
standardised
score of 75 80
Some difficulties with forming
relationships and social
interaction skills, play and imagination
skills and
behaviours e.g. shows some
inappropriate responses in
social situations and/or some difficulties
in playing with peers.
Moderate learning
difficulties in
acquiring basic
conceptual
understanding
(e.g. colours,
shapes),
symbolic,
imaginative and
make believe
play.
Working below the
age
expectations of
EYFS.
Difficulties with
forming
relationships and
social
interaction
skills, play and
imagination skills
and
behaviours.
Difficulty coping
with changes in
routine/environ
ment.
Needs profile 3
Needs profile 4
Difficulty in regulating emotions
(e.g. laughing at others distress)
Shows extreme responses in when
experiencing changes in
routine/transition.
Displays bizarre
ritualistic/obsessive repetitive or
stereotyped behaviours
Difficulty in regulating emotions
(e.g. laughing at others distress)
including self-harming and
selfstimulation.
Behaviour severely withdrawn, bizarre,
obsessional.
Moderate to severe
learning difficulties,
significant
Severe learning
delay acquiring
difficulties and
basic
global delay,
conceptual
affecting selfhelp Needs are severe,
understanding
Mild to moderate
long term and
and ability to
(e.g. colours,
learning
complex.
function
shapes),
difficulties.
independently
symbolic,
Cognitive
Cognitive
.
imaginative & make Needs are long
assessment
assessment below
term.
believe
play.
Unable to access
below the 5th
0.5
Cognitive
and make any
centile or a
Rate of learning
centile or a
assessment below
progress
standardised
&
standardised
2nd
within EYFS
score of below
score of 70 - 75 acquiring new skills
without
55
is slow.
centile or a
significant
standardised
Significantly (½
score of 55 to 70 interventions and
chronological
adult support.
age) below age
expectations of
EYFS
Fairly often
disrespectful
to staff and or
pupils
Fairly often will
interrupt and
seek attention
inappropriately
Known to have
bullied others in
last 6 months
Significant
Often disrespectful
Severe
difficulties with
to staff and or
difficulties with
forming
pupils
Shows only
forming
relationships and
Often interrupts
minimal
relationships and
social
and seeks
respect for
social
attention
interaction
adults and peers
interaction
skills, play and
inappropriately
skills, play and
Very difficult to
imagination skills
Fairly often
imagination skills
direct
and
disrespectful
and
of property
behaviours.
Often intimidates
behaviours.
Feared as a bully,
and readily resorts
Extreme
having
Child shows little
to physical
difficulty coping
physically hurt
or no
aggression
with changes in
others
communicativ e
routine/environ
intent.
ment.
Needs profile 0
Needs profile 1
Needs profile 2
Dispositions
and Attitudes
Specific
Learning
Difficulties
(green
columns
relate to
school age
pupils)
No significant needs in this area.
Impulsive behaviour and
inconsistency when responding
to boundaries and correction.
Occasionally disruptive.
Sometimes lacks curiosity and
interest in the environment and
is unmotivated to explore and
learn.
Some difficulty with subject
specific / polysyllabic words
Cognitive abilities within broad
average levels and above
Reasoning skills fine
No EAL
Notable phonic versions of
spellings
Reading 2-3 yrs behind CA
May have fine and/or gross
motor difficulties
Dyslexia screening test at risk
quotient (DST ARQ) 1.0 – 1.4
Occasionally
physically/verb
ally aggressive
Often lacks
curiosity and
interest in the
environment
and is
unmotivated to
explore and
learn.
Needs profile 4
Highly resistant
to
interventions/a
dult support.
Frequently
disruptive.
Behaviour is
variable
dependent on
context. May
be in conflict
with
peers/adults.
Needs profile 3
Fairly often
distracted from
task
Sometimes
inattentive to
teacher and
other support
staff
Finds group
learning
activities in a
variety of
situations
difficult
Regularly
shows
physical/
verbally
aggressive &
intimidating
behaviour to
peers & adults.
Disruptive on
daily basis.
Shows little
interest in their
surroundings
and when
learning new
skills. Rarely
leads own
exploration and
play.
Finds it very
difficult to cope
with most
learning
situations as
an individual
or as part of a
group
Shows very
little interest in
school work at
all
Mild learning difficulties
Very uneven profile of skills
Needs differentiated work and
support with conceptual
understanding and reasoning
across the core curriculum.
Difficulty in all literacy based
subjects
Cognitive assessment below the
5th centile or a standardised
score of 70-75 or presents with
a very uneven cognitive profile
Severe difficulties with HF words
Reading 6-7 years behind CA
Severe fine or gross motor
difficulties
DST ARQ 2.0+
Highly uncooperative and
very resistant to interventions
and adult support. Behaviour
regularly aggressive on a
frequent and sustained basis to
peers and adults.
Shows no interest in their
surroundings and when learning
new skills. Never leads own
exploration and play.
Severe difficulties in accessing
any written material.
Profile outline:
Foundation years pupils
School aged pupils
0
Universal services (support expected from within existing resources)
‘Quality First Teaching - Universal services’. Support expected from within existing resources
1
‘SEN Support - universal services (support expected from within existing resources)
‘SEN Support or Wave 2/3 intervention. Needs met from within own and delegated resources
2
‘SEN Support’ - some additional short-term support for setting to fully assess needs and meet
within existing resources longer term
‘SEN Support' or Wave 2/3 needs met from schools own and delegated resources, with
support from outside agencies. Education, Health and Care Assessment may be appropriate.
3
‘SEN Support- Additional needs identify longer term support required to ensure child is able to
fully access EYFS. Education, Health and Care Assessment may be appropriate.
4
Complex needs - may not be able to access EYFS without specialist support. Where the
setting is able to demonstrate capacity longer term support required
Education, Health and Care Assessment may be appropriate. Needs likely to be beyond
school’s own and delegated resources. Support identified through a Statement / EHCP likely
required for pupil to fully access curriculum in mainstream or special school
‘Statement / EHC Plan’ Complex, long-term needs that would reasonably be met through a
statement / EHCP and most likely placement in special school