REQUEST FOR A STATUTORY EDUCATION, HEALTH AND CARE
ASSESSMENT
Before sending this request please ensures that all parts of the form below are
completed and any additional information listed below is included. Please add
additional boxes if required.
The parent(s)/carer(s) and the Early Years SEND Team/setting should then
sign the form.
Included
Family Conversation (separate form)
My Views (separate form) only if appropriate
Professional Reports
Attendance (if appropriate) , attainment and progress
information (EYFS Tracker,Developmental screens,Portage
tracker, IEPs )
CAF minutes (if available)
DETAILS OF CHILD/YOUNG PERSON
Child's Name:
Date of Birth:
Current Setting:
EYFS Year Group
Child’s Learning and Development stage (complete for a child within the Early Years
Foundation Stage)
Strengths
Area of Need
Enter most recent Early
Years Foundation Stage
EYFS Tracker & or PSES
Development Screen
levels
Cognition and
Learning
EYFS
Cognitive Skills (creating
and thinking
critically)(Literacy,
Mathematics
Understanding the world,
Expressive arts and
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design)
Motivation /
Organisational /
Independence Skills (
Active learning)
Play Skills (Playing and
exploring)
Communication
and Interaction
EYFS
Concentration and
listening skills
(communication and
language Listening and
attention)
Language
Skills(communication and
language understanding
and speaking
Social, Emotional
and Mental
Health(Wellbeing)
EYFS
Social Skills (Personal
social and emotional
development Making
relationships)
Behaviour (Personal
social and emotional
development managing
feelings and behaviour)
Emotional
Development(Personal
social and emotional
development managing
feelings and behaviour )
Self-esteem/Confidence
(Personal social and
emotional development
self-confidence and selfawareness)
Physical/Sensory/
Medical
EYFS
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Medical Issues / Health
(physical development
health and self-care)
Motor Skills (Physical
development moving and
handling)
Self-help Skills (physical
development health and
self care)
RESULTS OF ANY RECENT STANDARDISED TESTS
Standardised Test Date
Percentile
Age Equivalent
EPS PIPS Levels
Health Visitor
SOGS
Wellcomm
assessment
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Please highlight the primary area(s) of identified need :
Cognition and
Learning
Communication
and Interaction
Social, Emotional
and Mental Health
Physical/Sensory/
Medical
Moderate
learning
difficulties
Speech &
language
difficulties
Social difficulties
Physical
difficulties
Specific
learning
difficulties
Autistic
Spectrum
Disorder
Emotional
difficulties
Visual
impairment
Severe learning
difficulties
Social
communication
difficulties
Other SEMH
difficulties
Hearing
impairment
ADD/ADHD
Medical
difficulties
Profound &
multiple
learning
difficulties
REASON FOR REQUEST
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Explain the reason for requesting this EHC assessment
You should consider the following areas:
Development , education , and learning:
Communication and interaction:
Friendships, and relationships:
Social, emotional & behaviour needs:
Independence, and self-help skills:
Physical, sensory(HI,VI) and health needs:
Support for the family:
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Which of these services has been working with the child/young person?
Report
Name of Professional
Date(s) of
included?
and contact details
involvement
(Y/N)
Integrated Early Years
SEND team(Pre School
Education Service)
Sensory and physical
Support Service
Early Years
CIASS Service (Speech and
language/Autism Service)
Early Years
Early Support Key worker
(CDT)
Educational Psychology
Service
Children’s Centre family
support worker
Early years Integrated
service Community
Paediatrician
Early years Integrated
service Speech and
Language Therapy
Early Years integrated
service Occupational
Therapy
Early Years integrated
service Physiotherapy
LAWS Team (Learning and
Wellbeing Service) EY
Reception
MGSS (Minority Group
Support Service)
Child and Adolescent Mental
Health Service (CAMHS)
Other – Please list below
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EDUCATIONAL ADVICE
Section 1: Support provided by Early Years SEND Education Services /Early Years maintained or non maintained Setting
Section 2: Additional support required
Section 3: Attendance (If Appropriate), attainment and progress information
In completing these sections, please consider each of the following areas, where appropriate, for each part:
Development, Education and learning: Communication and interaction: Friendships, and relationships; Behaviour and emotional needs:
Independence and self-help skills: Physical, sensory and health needs; Support for the family
SECTION 1
WHAT SPECIFIC SUPPORT HAS BEEN PUT IN PLACE TO MEET THE NEEDS OF THIS CHILD (In maintained or non
maintained Early Years Setting or home)?
INTERVENTIONS
What was the type of intervention?
When did this
intervention take
place?
How long and how
often was the
intervention?
Was the
intervention
individual or in
a group? (if
group, what
size?)
Who
provided the
intervention?
How did the intervention meet the child’s
needs? What was achieved?
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SECTION 2
WHAT ADDITIONAL SUPPORT, IS NEEDED TO OVERCOME THE BARRIERS TO LEARNING FOR THIS CHILD?

Use this table to identify the short-term targets and the interventions needed to meet the child’s needs. These should relate to the
following areas: Development, Education and learning: Communication and interaction: Friendships, and relationships; Behaviour and
emotional needs: Independence and self-help: Physical, sensory and health needs; Support for the family
 Include who delivers the intervention and the precise frequency of these interventions. If you will be responsible for devising and
monitoring the interventions with maintained and non maintained Early Years settings staff and parents/carers but staff/parents/carers
will be delivering the interventions on a regular basis these arrangements should be detailed.
 Your advice should include the expected duration of the intervention and dates for review. It should also identify the expected outcome
of intervention and how it will be measured
 In order for the EHC Plan to meet the requirement to be clear, accessible and helpful it is essential that any intervention is
specified and quantified
What the child
needs help with
over and above
Who is going to do this
Outcome
By when
that which
What does this help look like?
and when and how
would typically
often?
be needed for a
child of their
age
Development
education and
learning
Communication
and Interaction
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Friendships and
relationships
Behaviour and
emotional
needs
Independence
and self help
Physical
sensory(HI VI)
and health
needs
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Support for the
family
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REFERRER
Parent submitting the request
Name of person submitting the
request
Early Years SEND team or Early Years
Setting submitting the request
Signature
Yes/No
Date
PARENT/CARER CONSENT
I/We give consent for the Early Years SEND Service /Early Years setting to
request a Statutory Education, Health & Care Assessment of my/our
son/daughter.
I/We confirm that I/we have read and understood all of the information included
in this request. I/We certify that the information, which I/we have provided, is
correct.
I/We understand that the information provided in this application will be used to
ensure that the council’s records are correct. It may also be shared with other
agencies and service providers to ensure that our son/daughter receives an
appropriate service.
Signature of parent/carer……………………….. Date…………………….
Signature of parent/carer……………………….. Date…………………….
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