SISS Speech and Language Communication Disorder Team 
Request for High Needs Support Form.
Please send this form, with the required evidence attached via email to:
sisupportservice@solihull.gov.uk

	Evidence Provided

(Please tick yes/no)
	
Pupil Name: 

Date of Birth:
			
Are Speech and Language Therapy service still involved with the C/YP?	Yes	No	
Has there been a further Speech and Language assessment (CELF) or SALT report since our previous involvement?
Please attach.	Yes	No	
Have you made a referral to any other services since our previous involvement?
	Yes	No	
Please state which services.

Has the child received an EHCP since our previous involvement
	Yes	No	
Please state the primary needs on the EHCP
		
Please attach a description of the specific barrier to learning currently being experienced e.g. what is your main concern that you would like support with?	Yes	No	
Please attach evidence of following the Graduated Response.
Show your current provision at Universal, Targeted and Higher Needs, (following the Solihull banding advice/SALT targets/SLCD Targets agreed on Advice Summary/EHCP doc
This is your Assess – Plan – Do – Review cycle.
Example: 
1)	Evidence of an observation carried out by SENCO/Communication Lead  following concerns raised and with consideration of:
a)	Strategies and resources agreed by SALT/CLD/SLCD Team
b)	Communication Friendly Checklist has been completed with emphasis on use of visuals and opportunity to talk before performing tasks
c)	Evidence of a narrative approach: Language Link/Language for Thinking/Time to Talk/Nelli/Black Sheep Press Nursery/reception Narrative approach/Talk for writing
2) Description/evidence of impact - what impact did this have on the child when used consistently for a period of time?	
Yes

No

	
Please attach evidence of a Needs Based Plan, or One Page Profile, that identifies the pupil’s strengths / areas of need, child’s views and how best to support the pupil.
	
Yes 
	
No

Evidence of on-going parent and school communication through partnership work e.g. most recent minutes from TAF/TAC meetings / regular SEND meetings with SENCo.  	
Yes

	
No
	
Number of Exclusions (Fixed Term and Internal), if applicable. 	

Reduced timetable documentation, if applicable.	Yes 
	No
	
Reintegration Plan, if applicable. 	Yes
	No	
School has parent permission to make the request for support and share information with the SLCD SISS Team.
	
Yes	
No	
Completed copies of the Teachers’ Views and Parents Views, Child’s views returned with this form. 	
Yes	
No 	
Name and role of person making this request (include email address)

Name of school or setting:
	
Date of request :