Setting Request for Education Health and Care (EHC) Needs Assessment.
PLEASE READ THE GUIDANCE AND CRITERIA DOCUMENT FOR EDUCATION,
HEALTH AND CARE NEEDS ASSESSMENTS REQUESTS BEFORE COMPLETING
THIS FORM.
If an EHC Needs Assessment is initiated this form will constitute all or part of the educational advice
and will be shared with other agencies as appropriate. It is the schools/settings responsibility to
obtain permission from relevant professionals when including additional evidence.
DETAILS OF CHILD/YOUNG PERSON FOR WHOM ASSESSMENT IS BEING REQUESTED:
First Name:
Surname:
Previous names (if applicable):
Gender:
Male
Female
(please circle)
Date of birth:
Address:
Name of all parent/carers with
parental responsibility:
Parent/carer address and
contact details (if different from
above). Please ensure a contact number
or email for parent/carer is included.
Is child/young person currently
looked after? If yes please
include which authority.
Ethnic origin:
Child’s first language:
Parent’s first language:
Details of any special
requirements which may be
necessary to support
communication with
parent/carer (i.e.
interpretation/signing).
Yes
Local authority (where applicable):
School details:
School child/young person is currently
attending:
May 2015.
No
Previous setting (where transfer has occurred in
the last year):
School year group:
Personalised approach:
What are the views, wishes and feelings of the child/young person:
(Hint – you might find it helpful to compile a One Page Profile or similar document to record these details. A One Page
Profile captures all the important information about a young person on a single sheet of paper under 3 simple headings
– ‘what people appreciate about me’, ‘what’s important to me’ and ‘how best to support me’. For further information on
One Page Profiles please refer to www.helensandersonassociates.co.uk/person-centred-practice/one-page-profiles/.
SPECIAL EDUCATIONAL NEEDS:
In which areas is the child experiencing significant need?
Main Need (tick one only)
Other Needs (as appropriate)
Communication/Interaction
Cognition/Learning
Social, Emotional and Mental
Health
Sensory/Physical
Date SEN was identified: ………………………………………………………………….
Reasons for making EHC Needs Assessment Request now:
May 2015.
SUMMARY OF STRENGTHS AND NEEDS.
Only complete those sections which are relevant to the child/young person’s needs – however please
complete the relevant sections fully and provide the requested additional documents as appropriate.
COMMUNICATION/INTERACTION:
Brief overview of learner’s strengths and needs in communication and interaction.
Please include an overview of the learner’s strengths in this area as well as their needs. This will also include
information about the outcomes identified for the learner to work towards and the impact of interventions offered.
Strengths:
Needs:
Identified Outcomes:
 Medium term (in the next year)

Short term (in the next term)
Summary of support interventions in place:
Impact of interventions (including measures used):
Communication/Interaction Tests and Assessments:
Test/Assessment
Date
Results
Evidence
submitted (tick)
COGNITION/LEARNING:
Brief overview of learner’s strengths and needs in cognition and learning.
Please include an overview of the learner’s strengths in this area as well as their needs. This will also include
information about the outcomes identified for the learner to work towards and the impact of interventions offered.
May 2015.
Strengths:
Needs:
Identified Outcomes:
 Medium term (in the next year)

Short term (in the next term)
Summary of support interventions in place:
Impact of interventions (including measures used):
Cognition/learning tests and assessments:
Curriculum Related Measures: EYFS, P-Scales, curriculum attainment, teacher Assessments, SATs.
Early Years Foundation Stage:
2 Year Progress Check:
Phonics Test:
EYFS Profile Scores – At end of Reception Year (where child is younger please provide details of
current assessment levels and their age at time of this assessment).
Area of Learning &
Development
Aspect
Making Relationships
May 2015.
EYF Stage at end of
Reception Year.
Or current EYF Stage (delete
as required)
Personal, Social & Emotional
Development
Physical Development
Communication and Language
Literacy
Mathematics
Understanding the World
Expressive Arts and Design
Self-confidence & selfawareness
Managing feelings & behaviour
Moving and handling
Health and self-care
Listening and attention
Understanding
Speaking
Reading
Writing
Numbers
Shape, Space and Measure
People and Communities
The World
Technology
Exploring and using media and
materials
Being imaginative
Curriculum Attainment (P-Scales/NC Levels etc):
Please enter levels for current and ALL previous year groups. NC Levels should be available prior to
September 2014. If alternative means of assessment are being implemented post September 2014
please provide details of the assessment score as well as the assessment tool/evaluation process.
Primary Phase
Year
1
Date:
English
Reading
English
Writing
Maths
Science
May 2015.
Year
2
Date:
Year
3
Date:
Year
4
Date:
Secondary Phase
Year
5
Date:
Year Year
6
7
(SAT) Date:
Date:
Year Year
8
9
Date: Date:
Year
10
Date:
Year
11
Date:
Attainment and Cognitive Standardised Tests:
Test
(Name of test
used)
Date
Age
Standardised
Score
Percentile
Evidence
Submitted
(tick)
Post 16:
For Post 16 students please provide details of courses currently being accessed and evidence of
progress within this course(s).
SOCIAL EMOTIONAL AND MENTAL HEALTH DIFFICULTIES:
Brief overview of learner’s strengths and needs in social, emotional and mental health.
Please include an overview of the learner’s strengths in this area as well as their needs. This will also include
information about the outcomes identified for the learner to work towards and the impact of interventions offered.
Strengths:
Needs:
Identified Outcomes:
 Medium term (in the next year)

Short term (in the next term)
Summary of interventions in place:
May 2015.
Impact of interventions (including measures used):
Social, emotional and mental health difficulties tests and assessments:
Rating scales, self-report measures, behaviour logs, analysis and impact of interventions.
Test/Measure
Date
Results
Evidence
submitted
(tick)
SENSORY/PHYSICAL.
Brief overview of learner’s strengths and needs in sensory and physical.
Please include an overview of the learner’s strengths in this area as well as their needs. This will also include
information about the outcomes identified for the learner to work towards and the impact of interventions offered.
Strengths:
Needs:
Identified Outcomes:
 Medium term (in the next year)

Short term (in the next term)
Summary of interventions in place:
Impact of interventions (including measures used):
May 2015.
Sensory/physical tests and assessments:
Test/Measure
Date
Results
Evidence
submitted
(tick)
ADDITIONAL RELEVANT INFORMATION – PLEASE LIST BELOW AND ATTACH.
Please provide any information which has not been covered above.
E.g – PSP, PEP, Early Help Assessment/Plan, TAC action plans, health care planning,
independent professional reports.
PLEASE ALSO PROVIDE EXAMPLES OF THE LEARNER’S WORK AND A COPY OF THEIR
CURRENT ATTENDANCE CERTIFICATE.
CURRENT SCHOOL PROVISION FOR THIS CHILD/YOUNG PERSON.
Please provide information about the school/settings best endeavours to support this child/young
person. As a minimum we require:
a) A copy of their individual provision map/support timetable.
b) Progress information for example their current Individual Education Plan or Individual Learning
Plan as well as reviewed copies.
Additional professional support/advice sought and implemented by setting.
Please provide details of the additional professional advice you have sought to support you in
meeting this learners needs and details of the advice given/impact of this intervention. We would
expect this request to have been at least discussed with a professional outside of the setting before
submission.
Name of
professional
providing
support/advice
and date.
May 2015.
Recommendations How has this
made
been
implemented?
i.e what has been
put in place and for
how long?
Impact of the
intervention?
What difference has
this made?
Evidence.
What is the
evidence of this
intervention? Is the
professional report
attached?
EVIDENCE OF CO-ORDINATED SUPPORT TO THE CHILD/YOUNG PERSON AND FAMILY.
Please provide any details of external professional support (current or historical) provided to the
child/young person and/or their family (if not covered above). Where appropriate provide reports.
OTHER THINGS WE WOULD LIKE YOU TO KNOW ABOUT CHILD/YOUNG PERSON AND
FAMILY.
Please provide details of any other information you would like us know – ideally in consultation with
the child’s parent or young person themselves.
For example any history, diagnosis, medication, self-help skills, likes/dislikes, strengths/difficulties, aspirations, main
areas of worry (if not covered above).
Parent/Young Person Consent for Request for Education, Health and Care Needs
Assessment.
Consent:
I am in agreement with the request for an Education, Health & Care Needs Assessment.
I agree to Southampton City Council seeking any relevant information from other professionals to
help them in deciding whether it is necessary to carry out an Education, Health & Care Needs
Assessment.
If an Education, Health & Care Needs Assessment is approved I agree to Southampton City Council
seeking further professional advice and/or assessment to help them decide whether it is necessary to
issue an Education, Health and Care Plan.
Freedom of Information and Data Protection.
May 2015.
Your details will be used in accordance with the Freedom of Information Act (FOIA) 2000 and the
Data Protection Act (DPA) 1998 or other appropriate legislation, and will be stored electronically. If
information you have provided is personal, as defined under the DPA, we will only use it for the
purpose for which you provided it. We only share your personal data with a third party if we are
required to do so by law or if we need to in order to provide the service you requested.
Parent/Carer/ Guardian Signature:
Young person signature (as appropriate):
Name and role of person making this request:
Please send this form and all associated paperwork to:
SEN Team
0-25 SEND Service
Ground Floor
North Block
Civic Centre
Southampton
SO14 7LY.
May 2015.
Date: