Request for information/advice from the Early Years setting to
support the statutory integrated assessment for a child
CONTEXT
This information is sought in accordance with the Children and Families Act 2014.
The Local Authority is seeking advice as part of an Education, Health and Care
Assessment.
Child Details
Surname
Forename
Unique Pupil No.
Date of Birth
Educational
Setting
YR Group
Home Authority
Child Looked
After Yes/No
Address
Parent/Carer
Name
Relationship
Address (If
different from
above)
Parent/Carer
Name
Relationship
Address (If
different from
above)
Phone Number
Phone Number
Type of Advice
Statutory Integrated Assessment
Review of EHC Plan
Statutory Re-Assessment
Conversion advice from a Statement to
EHC Plan
Advice Givers Details:
Name
Job Title
Qualifications
Setting Name
Setting
Address
Key Stage
Attendance Record- please provide as much information as possible
Name of
Educational Setting
Period (Dates)
Actual
Attendance (No.
of Sessions)
Possible
Attendance (No. of
Sessions)
Percentage
Attended
Section A
The Identified Special Educational Needs – What do you consider the child's
difficulties to be which are acting as barriers to curriculum access and progress? You
may wish to complete more than one section.
Communication and
Interaction
Cognition and
Learning
Social, Emotional
and Mental Health
Difficulties
Sensory and/or
Physical Needs
Independence and
Self Help
Are there any additional significant factors? – If the answer is yes please attach
copies of relevant information/advice
Health Yes/No
Attendance Yes/No
Home Circumstances
Yes/No
Social Relationships
Yes/No
Section B
Attainment/Ability/Assessments/Milestones met – Please give results from any
developmental standardised assessments and complete the form at Appendix 1.
Section C
Support provided and Funding – All Early Years settings are provided with
resources to support those with additional needs, including children with SEN and
disabilities. Please therefore identify the provision made from the settings delegated
budget to address the child's needs and indicate whether you have applied for
additional inclusion support from the Local Authority:
Additional
Inclusion Support
Current support arrangements: Give details of the targeted support the child
received that was additional to and different from normal arrangements
Type of
Provision
Objective of
Provision
Frequency
& Duration
Delivered
by
Start
Date
Review
Date
Outcomes
(Achieved,
Partially
Met, Not
Met)
Additional Support – What additional support do you feel is required over and
above that already provided?
Outcome to
Achieve
Steps towards
Achieving Outcome
Timescales to
Achieve Outcome
Special Educational
Needs Provision
Required
Professional Involvement – List details of attached reports/evidence from
appropriate services
Service Provided By: (Name
& Role)
Name of Advice
Giver
Role
Signature
Date of
Report
Date
Assessed
Brief Description of Evidence
Attached
Date of Completion
Appendix 1
Attainment/Ability/Assessments/Milestones met – Please give results from any developmental standardised assessments
Early Learning Goals
Date
Age
Communication &
Months Language*
Listening
Key for completion
Emerging
1
Developing
2
Exceeding
3
Not Assessed
A
Due to
Absence
Understa
nding
Speaking
Physical
Development*
Personal, Social &
Emotional*
Literacy*
Maths*
Understanding
the World*
Expressiv
e Art &
Design*
Moving &
Handling
Self
Confidence
Awareness
Reading
Number
People &
Communi
ties
Exploring
using
media &
materials
Health & Self
Care
Managing
Feelings
Behaviour
s
Making
Relations
hips
Writing
Shapes,
Space &
Measure
The
World
Technology
Being
Imagina
tive