Before completing this form please read the ‘Referral Form Guidance Notes’

Children’s Services Directorate

EHC Plan Referral

Please tick one main referring agency:

School

Early Years Setting

Other Educational Setting

Social Services(Contact Name)

Health(Name service)

Parental Referral

Self-referral

CHECKLIST BEFORE SUBMITTING REFERRAL

1. Please check that you have completed all the boxes of your relevant sections and that all copies of relevant documents are included and clearly labeled. (Please ensure that you have the author’s permission to forward their reports/letters, etc.)

2. Education settings must include copies of the evidence detailed in section 4:

i. The current intervention plan (IEP, IBP, Early Goals, Pastoral Support Plan, etc). Provide a summary of evidence of your intervention to the social, emotional and mental health needs of a child/young person rather than extensive behavior logs and descriptions.)

ii. No more than the last 2/3 previously evaluated intervention plans

iii. Salford’s Costed Provision Map – this should show the Individual Child’s Provision Map rather than the whole school Provision Map (showing the child’s provision for 3 terms including the previous, current and next planned school term)

iv. Written evidence by a Salford Education Psychologist (at least 2 cycles of ‘Set It, Check It’ interventions) or equivalent from an independent educational psychologist. If not, please explain.

3. The child/young person’s completed ‘My Story’.

Tick ()

To ensure that only relevant documents are considered by the SEN Panel please do not submit samples of the child/young person’s work, photographs, or extensive logs and

descriptions of incidents. Thank you for your co-operation.

SECTION 1. CHILD’S DETAILS

Surname First Name

Date of Birth Sex M/F

Address Postcode

School Year Group

SECTION 2. PARENTAL DETAILS (please detail all parents / carers to be notified)

Name Parent/carer

Address (if different from pupil)

Postcode

Tel: home Mobile

e-mail

Has parental responsibility? Y/N

If No, please indicate name and address of person having parental responsibility.

Name

Address

Name Parent/carer

Address (if different from pupil)

Postcode

Tel: home Mobile

e-mail

Has parental responsibility? Y/N

If No, please indicate name and address of person having parental responsibility.

Name

Address

Do any of the parents or carers require help with written English? Y/N

Do any of the parents or carers require the help of an interpreter? Y/N

REFFERALS CANNOT BE PROCESSED WITHOUT PARENTAL AGREEMENT

School or Setting Advice for Education Health Care Plan Assessment

SECTION 3. SCHOOL’S PEN PORTRAIT FOR CHILD NAMED IN SECTION 1

School/Setting SENCO Name

Address Tel:

Date of Admission

Pupil / Young UPN

Current Year Group

Other education settings attended in last 2 years

Outline details of any Social Care involvement including the level of need e.g. Team Around the Child / Child in Need /current care status and planned response.

Please provide name of current Social Worker, if applicable.

Looked After Child/Young Person

Yes/No If Yes, name of home Local Authority:

Term 1 Term 2 Term 3 Fixed Permanent

School Attendance in last 12 months

Total Exclusions

Term

Common Assessment Framework (CAF)Provide details of CAF interventions. If not, please explain why this has not been pursued

SEN Areas of Need/ Difficulty

Either Tick the most severe need or If complex, try to prioritise 1-4

Communication and Interaction

Cognition and Learning

Social, emotional and mental health needs

Sensory and/or Physical Needs

Date when additional needs were first identifiedDescription of needs in each of these areas where you feel able to comment- including strengths and weaknesses

Educational Needs

Health Needs

Social Care Needs

Please provide a list of external agencies involved with the child/young person in the last 12 months

Description of Current Provision:

SECTION 4. EVIDENCE OF CHILD’S ADDITIONAL NEEDS, PROGRESS TOWARDS TARGETS AND SUCCESS CRITERIA

Targets set for child in school/setting including – where appropriate:

National Curriculum Targets/ APS/ EYFS

Early Learning Goals IEP / IBP Targets (not

behaviour logs) GCSE Targets Course Targets Other

Progress against these targets over the previous 12months, including:

Progress towards targets set with child

Child’s progress in relation to peers/Chronological Age:

Evidence of actions already taken by the child’s school/setting to show that it has responded appropriately to the requirements of the National Curriculum by supporting the child to overcome difficulties.

Evidence that where some progress has been made, it has only been as the result of much additional effort and instruction at a sustained level beyond that usually commensurate with

provision through Support and Intervention Bands (SIBs). Evidence of use of the Notional SEN funding for this pupil – a Salford Costed Provision Map must be attached.

Date completed & Attainment

Level

Assessor/

Author

Organisation/

Agency

Attached Y/N

Assessments in school (list all relevant) including current NC levels

Evidence/reports provided by other professionals (attach all reports during the past 6 months if you believe they are still relevant).

Evidence of Educational Psychology involvement (attach any reports/assessments 6 months old or less)

In your view, please detail/ outline anticipated outcomes and success criteria for this child following agreement to assessment and provision of any additional support and resources from the Local Authority.

NB. Please do not detail types of setting/ provision

(You could use the Education, Health and Care (EHC) Assessment Professional’s Summary Sheet at the end of this form if you prefer)

HEALTH AGENCY REFERRAL FOR EDUCATION, HEALTH, CARE PLAN ASSESSMENT

(N.B. Only to be completed by referring Health Professional)

SECTION 5. DESCRIPTION OF CHILD’S HEALTH NEEDS

Health Agencies Involved

Contacts:Name of Key Worker

Telephone

E mail address

Summary of child’s health needs

Describe how the child’s medical need(s) is likely to impact on their educational progress.

Please append reports completed within the last 6 months (if still relevant).

SOCIAL CARE REFERRAL FOR EDUCATION, HEALTH, CARE PLAN ASSESSMENT

(N.B. Only to be completed by referring Social Care professional)

SECTION 6. DESCRIPTION OF CHILD’S SOCIAL CARE NEEDS

Named Social Worker

Contacts:

Telephone

E mail address

Summary of child’s Social Care needs

Describe how the child’s Social Care needs are likely to impact on their educational progress.

Please append reports completed within the last 6 months (if still relevant).

SECTION 7. REFERRERS’/EDUCATIONAL SETTING SIGNATURES

I have agreed to this referral being made for (child’s name) and am willing to share the attached information with parents and other professionals /Following a parental referral I agree to share the attached information with parents and other professionals

Agency/SENCO Signature Date

SECTION 8. CONSENT FROM PERSON WITH PARENTAL RESPONSIBILITY

I have agreed to this referral being made for my child (child’s name) and give permission for the information to be shared with school, Local Authority and other professionals.

Name Signature Date

DATE REFERRED:

Send the completed referral and supporting evidence to:

SEN TeamSalford City Council Burrows House,

Wardley Industrial Estate, 10 Priestley Road,Swinton, M28 2LY

or electronically to

SpecialEducationalNeeds@salford.gov.uk __________________________________________________________________

What happens next?

The referral papers will be allocated to a case worker who will process them and arrange for them to be placed on the agenda of Salford’s SEN Panel for a decision to be made.

The Authority has four weeks (locally agreed timescale) in which to make a decision about whether or not to agree to initiate a statutory assessment of the child/young

person’s Education, Health and Care needs

Appendix AFair Processing Notice

Salford Council’s SEN Team works with a range of teams and agencies within the Council and the NHS to provide support to children and young people with Special Educational Needs and Disabilities (SEND) and their families.

These include:

Education Psychology Service

Learning Support Service

Education Welfare Officers

Children with Disabilities Team

Social Care

Ethnic Minority and Traveller Achievement Service

Youth Offending Team

Salford Royal Foundation Trust

Salford Clinical Commissioning Group

In order to draw up an EHC Plan the SEN Team needs to consider the child/young person’s difficulties across education, health and care where necessary. To achieve this the SEN Team will sometimes need to exchange information with other teams in the NHS and Local Authority. This includes some basic details such as name, address, date of birth and any other appropriate information that you might have given to a member of the team, for example:

Who is in your immediate family and the type of support your family needs

Which agencies might have helped you in the past

Details about gender and ethnicity

This information is held securely on a number of databases on Local Authority and NHS IT systems. With your consent, we will share this information, but only if it is beneficial to you. Your information will not be passed on to anyone else unless we are legally bound to do so or if there is a risk of serious harm to you or anyone in your family. This is in line with the principles of the 1998, Data Protection Act. Under

this Act you also have a right to see a copy of the information we have on your family.

In order to make sure that you get the right help at the right time, we would like to update your details on a regular basis so that our records are current. We will do this by asking you directly to let us know if any of your details have changed.

If you require any more information you can speak to one of the SEN team members on 0161 778 0410.

Appendix BEducation, Health and Care (EHC) Assessment

Professional’s Summary(Insert Professional Area eg. SALT, Educational Psychologist)

The purpose of this document is to identify priority outcomes sought for the child or young person undergoing an EHC Assessmentand help in the development of an EHC Plan. Please use the following document to summarise the child’s/ young person’s needsacross education, health and social care in those areas where you feel able to comment and append it to your report.

Recommendations included below should adhere to all current clinical/professional guidance and include both short-term and long term goals.

Summary of Needs/Conclusions

Short Term Outcomes(Immediate/within 12

months)What do we want to

achieve?

Recommended ProvisionWhat/how/when/who?

Success CriteriaHow will we know we

have been successful?

Education

Health

Care

Long Term Outcomes (across a key stage)What do we want to achieve?

Education

Health

Care