NAME
Draft/Final Education, Health and Care Plan (Version No?) 
DATE
Date Initial Plan Issued: 	

My personal information:

My first name:		My surname:		
I prefer to be called:		I was born on: 		
My gender:		My ethnicity:		
I live at:		My first language:		
My NHS number:		My Health Authority:		
My Unique Pupil Number:		My Care First number:		
Looked after by the Local Authority  ? 

Child in Need? If yes, dates: 
	
My parent/Carer/Social Worker who has Parental Responsibility:

	
Their address is:
	
Their phone number and email is:

	
I am over 16 but would like my plan and letters also sent to: 

	

These are my family members and other people who are important to me and supporting my plan:

Name	Address	Email/Tel. No.	Relationship to me.	

				

NAME: 

Section A: Child/Young Person’s and Parents’ views
Child’s/Young Person’s History (please provide a brief history. You may wish to think about health, eating/sleeping, developmental milestones, social skills and relationships, attitude to school, taking part in activities in and out of school)

	

Things that xxx enjoys doing and are important to them:
	
Things that xxx would like to learn or get better at:

Things that xxxx’s parents/carers would like them to learn or get better at: 	
Xxxxxx’s hopes, goals and dreams for the future (please consider ideas of jobs or types of jobs, where they may like to live, family, travel etc)

Xxxx’s parent’s and/or carer’s hopes, goals and dreams for their future

Xxxxxx communicates by: 	

Section B: The child or young person’s Special Educational Needs
Xxxxxx has a diagnosis of ……… and therefore has needs in the areas of OR xxxxx has needs in the areas of 
-	Communication and Interaction
-	Cognition and Learning
-	Social, Emotional and Mental Health
-	Physical and Sensory
(delete as required) 
Communication and  Interaction	
Strengths	 
	
Special Educational Needs	 

Cognition and Learning	
Strengths	
 	
Special Educational Needs	.

 	
Social, Emotional and Mental Health 
	
Strengths	
 	
Special Educational Needs	 	
Physical and Sensory	
Strengths	
	
Special Educational Needs		

Section C: Child or Young Person’s Health Needs which relate to their SEN
1.		Educational/Social Impact		
2.	Health needs, identified through the EHCP needs assessment that relate to their SEN
Including who diagnosed/confirmed 		
3.	The Clinical Commissioning Group may also choose to specify other health care needs which are related to the child or young person’s SEN ( for example, a long term health conditions that may need management in a setting) 		

Section D: Social Care Needs which are related to their SEN or to a disability
	Description of need	Impact	

			

Sections E & F: Outcomes and Special Educational Provision
Communication and Interaction	
Specific                       Measurable                       Achievable                         Realistic                        Timely	
Outcome (E)	Who will deliver this?	Provision (F)	
By the end of Key Stage ….. xxxx will			

Cognition and Learning	
Specific                       Measurable                       Achievable                         Realistic                        Timely	
Outcome (E)	Who will deliver this?	Provision (F) 	
By the end of Key Stage ….. xxxx will			

Social, Emotional and Mental Health	
Specific                       Measurable                       Achievable                         Realistic                        Timely	
Outcome (E)	Who will deliver this?	Provision (F)	
By the end of Key Stage ….. xxxx will			

Physical and Sensory 	
Specific                       Measurable                       Achievable                         Realistic                        Timely	
Outcome (E)	Who will deliver this?	Provision (F)	
By the end of Key Stage ….. xxxx will			

Section G: Any  Health Provision reasonably required by the learning difficulties or disabilities which result in the child/YP having SEN	
Specific                       Measurable                       Achievable                         Realistic                        Timely	
Outcome 	Who will deliver this?	Provision (G)	

Section H 1: Any Social Care Provision which must be made for a child/YP under 18 resulting from s2 Chronically Sick and Disabled persons Act 1970	
Specific                       Measurable                       Achievable                         Realistic                        Timely	
Outcome 	Who will deliver this? 	Provision (H1)	

Section H 2: Any other social care provision reasonably required by the learning difficulties or disabilities which result in the child/young person having SEN	
Specific                       Measurable                       Achievable                         Realistic                        Timely	
Outcome 	Who will deliver this? 	Provision (H2)	

Section I:  Placement 

Type AND name of  Placement: 

Section J:  Personal Budget: N/A
Has a Personal Budget been requested Y/N
Has a Personal Budget been agreed Y/N
Type of support	Targeted to which Outcome?	Cost	Body responsible for funding	Is a direct payment available?	Has a direct payment been agreed?	

						
Total		£				

Arrangements for reviewing this plan: 

The next formal review of this plan will take place no later than DATE 
(note: period may be less than 12 months if a transition year) 

This plan was agreed by:
Signed: 
Duly Authorised  Officer of the Local Authority	Signature:
	Date:

Section K:

Information and advice used for this plan: 

Number e.g. K1, K2	Type of report	Author and Job Title	Dated	

				

				

For Office Use only:
Funding Band (if applicable)