STATUTORY EDUCATION, HEALTH AND CARE ASSESSMENT
(all boxes on this form will expand as needed)

Name of the person making the request	
	
Relationship to the child/young adult		
If a parent/carer is making the request has this been discussed with your child’s education setting?	Y/N	
If you are a young person making this request for yourself, has this been discussed with your school or college ?	Y/N	
If a professional is making the request has this been discussed with the child’s parent/carer?	Y/N	

Education Health & Care (EHC) Needs Assessments/Annual Reviews of Education Health & Care Plans are part of a statutory process under the Children & Families Act 2014, Special Educational Needs & Disability Regulations 2014 and the SEND Code of Practice 2015.  
 
Statutory means that the local authority is required by law to provide a service. This is our legal basis for requesting, obtaining, and sharing information about you or your child. Without the information, we would not be able to provide that service to you. We will always listen to you about any concerns you have about information being shared and will look at how we can respect your wishes but we will need to share information in order to undertake our statutory duties. 
 
Information has to be requested and shared with Education, Health & Social Care colleagues plus other relevant involved professionals for the purposes of an EHC Needs Assessment, and if a Plan is issued, for the duration of the Plan. These will depend on the needs identified but it will always only be for these purposes. 

In the event of formal consultation for nursery/school/college being required, SMBC will share the EHC Plan and associated appendices with relevant educational settings.  If the parental/young adult preference is not the catchment area setting, SMBC will share these documents with the catchment school, and parental preference, as part of the formal consultation process or with any other educational setting that SMBC may consider to be appropriate to meet the special educational needs in the EHC Plan.

If you would like more information about how we handle your data please read the privacy statement in this link 
https://www.solihull.gov.uk/About-the-Council/Solihull-Council-Statement/Childrens-services-and-skills/Special-educational-needs-and-disabilities

Please sign the declaration below:
I give consent for information to be shared as above for the purposes of the assessment and, should an EHC Plan be issued, for the duration of the Plan in order for the local authority to undertake their statutory obligations.

Where a young adult is aged over 16, the local authority requires their signature.

Parent/carer’s consent/Social Worker with PR if CLA  (required for all under 16) 	
Signature		
Name		
Relationship to the child		
Date	*insert date*	
Young Adult’s consent (required if 16 or above)	
Signature 		
Name		
Date	*insert date*	
The local authority are changing the way in which correspondence is shared with parent/carers. Most letters and documents are now shared via email. This means you get correspondence faster than you would via post.
	
Do you give consent for the local authority to share documents and letters with you via secure email?		

The decision to conduct an EHCP assessment is taken in Solihull Metropolitan Borough Council by a multi-agency panel. From September 2022 there will be an observer from Solihull Parent Carer Voice on this panel – if you DO NOT wish for this parent to be present when your case is discussed please tick this box ☐

Part 1: PERSONAL DETAILS 

Details of the child or young adult	
*Surname		*First name		
Middle name(s)		*Preferred name if different 		
*Date of birth (dd/mm/yy)		Gender
Identifying Gender if different from above		
Ethnicity		Religion		
Home language		*NHS number (on clinic letters or in Red Book)		
*Email address		*Telephone number		
*GP details: 		*Preferred method of contact		
*Home address	

*Main contacts (those with Parental Responsibility) or the nominated contact for a YP 16 or over if want information sent to someone else..	
*Name(s)		*Relationship to child/young adult		
*Home language		*Preferred method of contact		
*Email address		*Telephone number		
*Home address	

*mandatory boxes 

Other key information	
Is this child/young adult subject to any of the following?	
	Yes/No	Dates/Authority	
Looked after/care leaver			
Adopted/Special Guardianship Order (SGO)			
Section 47 – Child Protection			
Section 17 – Child in Need			
Early Help			
Child of Armed Service personnel			
Youth or Adult Custody 			
Continuing Care Package			
Name of current nursery/school/college 		
Description of main presenting need	
Please indicate the main category of need (as set out in the SEND Code of Practice)

Communication & Interaction e.g ASD, SLCD 

Cognition & Learning 
e.g. learning disability, dyslexia 

Social Emotional & Mental Health 
e.g behaviour, anxiety

Sensory and/or Physical 
e.g hearing or visual impairment	

Details:

	

Part 2: PROFESSIONAL INVOLVEMENT 

Please list any relevant professionals that have assessed or been involved with this child/young adult and their contact details where possible. Include copies of any reports to help us with our decision making.	
Service	Named professional and email address	Tick if seen in the last year	Tick if a report is attached	Tick if a referral has recently been made/the child/YP is on a waiting list 	
Early Years Team 
					
SISS Service
					
Child & Adolescent Mental Health Service (CAMHS/SOLAR)					
Adult Mental Health Service					
Educational Psychologist
					
Medical professionals/ health professionals (e.g. Paediatrician, Health Visitor, School nurses, Community LD Nurse)					
Occupational therapist
					
Physiotherapist
					
Speech & language therapist					
Social Worker
					
Other

Part 3: CHILD/YOUNG PERSON & PARENT/CARER VIEWS 
To be completed by, or with, parent/carers/young person

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)

	

The views, interests and aspirations of the child/young person	
•	How do they give their views and communicate?

•	What are their interests and what do they like doing?

•	What is important to them?

•	What do they dislike?

•	What do they want to achieve/learn to do/be better at?

•	What are their aspirations for the future?

•	What are they good at?

	

Parents/carers views and aspirations for their child’s future	
•	What are your future aspirations for your child? e.g. to be as independent as possible, to have a job, to make friends, to live a full and happy life.

•	What support do they currently get and what is the impact of this? 

•	What are your reasons for making the request for a Needs Assessment and what support do you think your child needs that they are not currently getting? 

•	What difference do you think having an EHCP will make to your child?

	

Part 4: EDUCATION INFORMATION – to be completed by school, college or other learning provider

Parent/young adults should not complete the education section if they are submitting this request independent of the education provider.

Details of the educational establishment	
Name of requesting professional		Setting name		
Role 		Setting address		
Telephone number		Email address		
UPN		School/college/learning provider number		

Please complete the section relevant to the child/young person. It is vital that attainment and progress data is included with this request. 

For Early Years: (please refer to the Early Years info on the Local Offer for further guidance) 

We have listed a set of common developmental ‘bandings’ to summarise a child’s skill level in age bands (0-6 months, 6 -12 months etc) which use the settings observation assessment but convert this into a common language for the purpose of EHCP requests. Please indicate the best fit band which the child demonstrates. You may also have other standardized assessments you can use to complement this summary which can be added to the further information box..

	Attainment 	
	Complete this section for EYFS children
Please give results from any developmental or standardised assessments	
Date of assessment		Assessment completed by		
Chronological age at time of assessing		Assessment information (further information)	

	
To evidence progress please add a previous summative assessment 	Age:

Date:
	Assessment information (further information)		
Current area of development – mark the development range which best fits the child for each area of their most recent assessment summary		
Solihull summative development bands	Communication and Language Development	Personal, social and emotional development	Physical development 	Literacy Development	Mathematics development 	
Early Learning Goal						
48-60m						
24-36m						
18-24m						
12-18m						
6-12m						
0-6m						
Previous Assessment	Communication and Language Development	Personal, social and emotional development	Physical development 	Literacy Development	Mathematics development 	
Early Learning Goal						
48-60m						
24-36m						
18-24m						
12-18m						
6-12m						
0-6m						

Attainment		
Complete this section for Key Stage 1, 2 and 3 pupils
Please give results from any developmental or standardised assessments		
Year group	
	Assessments completed by			
Subject	Date of assessment	Chronological age at time of assessing	Assessment used	Level	Age equivalent	Progress over last 2 yrs 	
Reading							
Writing							
Spelling							
Maths							
Science							
Please add any additional standardised testing undertaken
Where there is a specific area of need, e.g communication & language/SEMH/Visual or Hearing impairment – please list any specific tests and results. 

		

Attainment	
Complete this section for Key Stage 4 and Post 16 students
Please give results from any developmental or standardised assessments	
Year group		Assessment completed by		
Subject	Date of assessment	Chronological age at time of assessing	Assessment used	Level	Age equivalent	
Literacy ( reading and comprehension) 						
Numeracy						
Details of qualification working towards or gained	Subject	Qualification, e.g. Entry level/GCSE/Functional skills/ASDAN	Predicted or achieved grade	

				
				
Please add any additional standardised testing undertaken
Where there is a specific area of need, e.g communication & language/SEMH/Visual or Hearing impairment – please list any specific tests and results. 

	
Details of work related experience/learning, e.g. vocational courses/work experience placements	

	
Please record here the progress and development over the last 2 academic years including towards the PfA outcomes. 		

Current support
SEND CoP 6.63 says: Where, despite the school having taken relevant and purposeful action to identify, assess and meet the SEN of the child or young person, the child or young person has not made expected progress, the school or parents should consider requesting an Education, Health and Care needs assessment. To inform its decision the local authority will expect to see evidence of the action taken by the school as part of SEN support.

The SEND CoP also says the LA can ask for APDR evidence of this support. 

Please attach involved professionals’ reports and Assess Plan Do Review (APDR) documents
These can be on a school template, or the LA template, but should clearly evidence that the graduated response has been exhausted and the impact of interventions and support	
Date identified as SEN Support level		
Attendance figure for the current academic year		

Provision Map – including frequency, hours, duration, size of group, etc. ( add rows as needed)	Impact	Date started	Date ended	

				

What targeted support is in place for the identified needs – based on expert reports e.g. EP, SISS, SLT etc ….				

Pen Portrait 

Please give a brief description of how the child/YP functions in the educational setting in each of these four areas  ( box can be expanded as needed) 	
Communication and Interaction 	Cognition and Learning	Social, Emotional and Mental Health	Physical and Sensory	
Strengths:

	Strengths:

	Strengths:

	Strengths:

Challenges:

	Challenges:

	Challenges:

	Challenges:

Part 5: HEALTH INFORMATION – provided by parent/young adult 

Does your child or young person have any existing diagnoses or health needs? Please list them here with the name of the professional who gave the diagnosis. 	

Please send any medical reports you would like to be taken into account. N.B we are unable to see any reports that might be on the NHS system 	

	Y/N	Details 	
Does your child have any health needs that are routinely addressed in school? E.g tracheostomy, epilepsy, PEG feeding etc. (this does not refer to regular medications e.g. ADHD meds, antibiotics etc)			
If your child is under 18, would you like your child to be seen by a paediatrician?
		Please note: if you select ‘no’ to the above we will only seek advice from the health care professionals who you have told us are currently working with your child.

Part 6: SOCIAL CARE INFORMATION – provided by parent/young adult

By completing the following questions  social care can look at how we may be able to offer assistance through services such as our local offer, or other support which may be offered if you meet service eligibility criteria. 

This information will be used to ascertain whether you require an assessment of need from Social Care as part of an EHC Needs Assessment. 

The questions below should be read in context of your (if young adult) / your child’s age and for very young children; consider if there is anything you are required to do that is over and above what could be reasonably expected of a parent with a child of the same age.

A description is required for each question but if helpful you can bullet point your answers.

Area	No	Yes	Please provide information where appropriate	Impact on everyday life 	
Have you had a parent/carer assessment through the Carers’ Trust?

If no would you like one?				n/a	
Has your child/YP accessed short break activities through solo/local offer? 

If no would you like more information about this?				n/a	
Does this child/young adult have a disability or other difficulty?

Does this child/young adult have behaviours that challenge, including any specific emotional or behavioural difficulties?					
Does this child/young adult need lots of help with personal care, e.g. bathing, dressing, toileting, which you may need help with?					
Does this child/young adult need help accessing activities or joining in friendships in a safe and meaningful way?					
Is family time together shared equally with other members of the immediate family?
					
Is there anything the parent/carer feels they need that would support in managing their child’s needs?					
Does this child/young adult & their family have a support network, e.g. family/friends/other forms of support?					

Part 7: SUBMISSION CHECKLIST

REMEMBER TO INCLUDE WITH THIS REQUEST:

Completed the attainment and progress information				
Complete the information about current provision				
Attach a current Provision map 				
Attach APDR cycles – clearly showing impact of interventions				
One or two samples of recent work, dated & annotated accordingly ( may not be appropriate for EYFS)				
Relevant reports from involved professionals, e.g. Health/Social Care, SISS, EP etc				
Any other relevant information to support the request				

Requestor’s signature		Requestor’s name		
Senior manager’s signature		Senior manager’s name		
Position		Date request submitted		

Please submit this form with the supporting evidence via email to
edsen@solihull.gov.uk 

If you have any queries relating to the submission of this form, including how to submit it if you do not have access to email,  please contact the EHCP Service on 0121 704 6690