Name of Child/Young Person:
Education Placement:
Date of last SEN Support Review Meeting:
This request should be discussed as part of the SEN support review meetings held by educational settings. The child and family/young person must have an opportunity to share their views and aspirations, be involved in the planning and agree to the request.
When considering if such a request should be made, national and local guidance on criteria should be taken into account.
The SEND code of Practice 2014 states that in considering whether an EHC needs assessment is necessary, the Local Authority should consider whether there is evidence that despite the early years provider, school or post 16 institution having taken relevant and purposeful action to identify, assess and meet the special educational needs of the children or young person, the child or young person has not made expected progress. In order to make that decision the Local Authority will need to take into account a wide range of evidence – please refer to check list below. (Code of Practice 9.14)
In Somerset a statutory assessment will begin when:

The child/young person has not responded to relevant and purposeful measures with High Needs intervention and requires a specialist placement or may require one within the next 18 months, for example at transition
OR

Requires significant integrated multi-agency response to address the severity and complexity of need where the child/young person will need significant assistance in the areas of: personal care, mobility, communication, equipment/accommodation, healthcare, education which may require support from Health and Social Care which may have been identified through a CAF
Every case will be treated on its individual merit within the context of the agreed polices. (See SEN Code of Practice Framework in Somerset [September 2014])
Checklist of documents that should be attached:

Evidence of academic attainment and rate of progress – see part 3 of the form

Evidence of the nature, extend and context of the SEN
– see part 4, please attach relevant documents (reports, monitoring and observations)
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
Evidence of the action already taken – see part 5, please attach relevant supporting documents such as timetables, provision maps etc

For young people over 18, evidence that there is a need for additional time, in comparison to the majority of other of the same age who do not have SEN, to compete their education or training
Please do not submit the following documentation:

Confidential information such as child Protection Plan, conference notes or any other notes without an appropriate authorisation

Any original documents

Information that includes names of other children
If the request for Statutory Assessment is agreed, a coordinator will work with the family and child or young person to gather existing report and ask for new ones where needed.
Professionals involved with the child/young person will be expected to come to a multi-agency meeting with the family to talk through their assessments.
Parent/carer/young person
’s consent for sharing information
I agree for the request for Education, Care and Health needs assessment to be submitted to Somerset Council
Signature Date
Relationship to child/young person
I understand that if an education, health and care needs assessment is agreed, information about Child's Name will be shared with professionals involved with
Child's Name to support the assessment and planning process. This will include information provided by the school or educational setting, assessment by an educational psychologist, classroom observation and report; medical assessment and health care reports, information from social care or family support services and other information and reports that are relevant to the needs of Child's Name.
I also give permission for Child's Name to undergo a medical examination, an educational psychologist assessment and a classroom observation as part of the statutory assessment process. Other assessments may also be required.
Signature Date
Relationship to child/young person
Completed form and additional documents should be sent to:
SEN Casework Team, County Hall, TAUNTON, Somerset, TA1 4DY
NB: Please email the SEN Area Base Coordinator to advise that Request has been made.
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Date of this SEN Support Review Meeting:
Attendees:
Name Status
Consulted but not attended
Attended
Reports
Submitted
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First Name Surname Preferred Name
Home Language/
Other languages spoken
Home Address
Gender Date of Birth Ethnic Origin
Do you or your child have a Social Worker? Parent Yes / No
Child Yes / No
Name of the Social Worker
Is this child in care to a Local Authority? Yes / No
Name of the Local Authority
Details of Care
Parent(s) or Carer(s)
Surname
Home Address (if different to child/young person)
Other Name
Relationship to child
Tel No
Parental Responsibility Yes / No
Mobile No
Email
Do you have a disability that we may need to consider when communicating with you? If Yes, please specify below:
Yes / No
Surname
Home Address (if different to child/young person)
Other Name
Relationship to child
Tel No
Parental Responsibility Yes / No
Mobile No
Email
Do you have a disability that we may need to consider when communicating with you? If Yes, please specify below:
Yes / No
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I NSERT
P HOTO
This section should be completed using a person-centred approach. It is all about what is important TO the child/young person. This information usually comes from face to face meetings or informal discussions; in order to avoid speaking ‘on behalf’ of the child or young person they should be encouraged to complete it themselves, if necessary with support. Children/young people may decide to use pictures, symbols, text or any other way of expressing their views, they can answer some or all questions, as relevant to them.
2.1 What do you think you did well last year?
2.2 What do people say they like and admire about you?
2.3 How do you need to be supported to be heard and to take part in making decisions?
2.4 Your views and your parents/ family’s views about your life
Child/ Young person’s Views Parent/Family's View
Hobbies, interests and favourite activities?
What is important to you?
What are your hopes and aspirations for the future?
What is working well?
What is not working so well and could be changed?
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2.5 Has anything happened in your life during the last year that you think was very important?
Yes No
If Yes, please describe below
Other child /young person’s contribution can be attached.
This part must be completed in full in all cases
3.1 Analysis of academic progress:
Please comment on facts that have had an impact on progress over Key
Stage and over the last 12 month period with reference to national expectation and DFE Progression Guidance. For example mention specific interventions that escalated progress, contextual background information, explain any inconsistences in assessment results.
3.2 Analysis of other progress:
Please comment on progress that has been made in other areas, for example: social development, independence, confidence?
3.3 Educational Attendance:
Attendance %
Please attach attendance certificate.
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Speaking
Listening
Reading
Writing
Maths
Science
Other school assessments:
Attainment levels listed below must be gained independently (without support), at the end of each year.
This part must be completed in full in all cases.
Note – please select foundation stage, school age or post 16 page, as relevant in each individual case.
KS1 KS2 KS3 KS4
1 2 3 4 5 6 7 8 9 10 11
English
12
Post-16
13 14
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Individual Progress Tracker – Early Years
This part must be completed in full in all cases.
Please complete the individual progress checker by writing in the EYFS stage together with an indication whether the child is Emerging (E),
Developing (D) or Achieved (A) in that area, for example 8-20mths (D). It would also be helpful to block in the appropriate colour below if possible.
Please use the Early Years Outcomes Guidance as a prompt to make best-fit judgements for each aspect of the EYFS
'A best fit judgement indicates the age/stage b and which best describes the child’s current development – the band where the child is mainly working'
You can provide additional evidence of progress; please use the Developmental Profile (Page 12 in the “Early Support Practice Guide to the
Early Year s Developmental Journal”).
Prime Areas Specific Areas
PSE CL PD L M UW EAD
Date
Age in
Months
MR SCSA MFB LA U S MH HSC R W N SSM PC W T EMM BI
Orange (Birth -11 Months) Pink ( 8-20 Months) Red (16-26 Months) Yellow (22-36 Months) Blue (30-50 Months) Green (40-60 Months) Grey (ELGs)
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Attainment levels listed below must be gained independently (without support).
This part of the form must be completed in full in all cases.
English
Previous Attainment Previous Attainment
Reading
Writing
Preparation for Adulthood
Employability
Independent Living
Participation in Society
Other: (Specific test assessment/tests)
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Maths
Last updated 16.04.15

Please describe the child/young person ’s strengths and needs and long term outcomes/short term targets. It is important to be specific about the type and severity of need . This information should be supported by the relevant evidence in relation to SEN for example existing evidence of assessments or diagnosis.
Cognition and Learning – provide evidence of any standardised assessments supporting an indication of current attainment and cognitive strengths/weaknesses and impact
Strengths
Needs
Evidence
Please list and attach
Long term outcomes
(key stage)
Short term targets
1.
2.
1.
2.
3.
Communication and Interaction, referring to talking, listening and taking part – describe strengths and needs from the assessment tools and reports; this should give indication of severity, frequency and impact.
Strengths
Needs
Evidence
Please list and attach
Long term outcomes
(key stage)
Short term targets
1.
2.
1.
2.
3.
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Social, Emotional and Well-being/Mental Health
– provide evidence of strengths and need based on evidence of assessments; the following examples of measures/audits should be also attached:

A sample of ABCC diaries/incident logs/structures observations

Boxall Profile or THRIVE

GL Emotional Literacy assessment
Summary below should give indication of severity, frequency and impacts of difficulties.
Strengths
Needs
Evidence
Please list and attach
Long term outcomes
(key stage)
Short term targets
1.
2.
1.
3.
Sensory, Physical and/or Medical Needs – relevant professional reports should be referenced for example Care plans, Manual handling plans, HI/VI assessments.
Summary below should summarise strengths and needs (as relevant) and indicate severity, frequency and impact.
2.
Strengths
Needs
Evidence
Please list and attach
Long term outcomes
(key stage)
Short term targets
2.
3.
1.
2.
1.
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Social Care Needs (to be completed only if relevant)
– please complete if children or young people are supported by social care services or if there is a pending referral to that service.
Strengths
Needs
Evidence
Please list and attach
Long term outcomes
Short term targets
1.
2.
1.
2.
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Please record current and recent (last 12 months) provision. When completing this part of the application the following guidance should be taken into account:

It is essential for the strategies listed below to be linked with needs and outcomes identified and advice from relevant support services


The provision should be proportionate to the type and severity of need
It is essential to clarify the evidence of impact
5.1 Special educational strategies and support
Level What is Provided?
How often
By
Whom
Date
Started
Date
Reviewed
Evidence of impact against agreed outcomes
Outcome
(please select one)
Whole
Class
Small
Group
Individual
Fully met
Partly met
Not met
Fully met
Partly met
Not met
Fully met
Partly met
Not met
Please attach:



A copy of the timetable or provision map
Current IEP/PLP/PEP or equivalent
Review of the previous terms IEP/PLP/PEP or equivalent
Is a medical care plan in place? Yes / No
If Yes, please attach a copy.
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5.2 Social Care, Health, travel to school or other additional support in place for the child/young person – please only complete if relevant (this could include voluntary organisations, after school clubs, short breaks etc).
What is provided?
How often?
By whom?
Date
Started
Date
Reviewed
Evidence of impact against agreed outcomes
6.1 Does the current range of support meet the agreed needs and outcomes for the child/young person? Yes / No
If No, what needs to be done differently? Please complete the table below.
Which strategies/support should be discontinued or amended?
What is recommended?
How would this impact on agreed outcomes?
6.2 This action plan will say what needs to be done this year, who is going to do it and by when. It can be about anything that is an important issue that has come out of 'what's not working'. It might be a job for anyone for example the school, parents, social workers or child/young person.
Action By Whom By When
Please note that a copy of this form must be given to parent/carer and/or young person and all enclosures made available to them on request.
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Signed: Child/Young Person
Parents/Carers
Headteacher
Review Facilitator
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