REHC 1
Request for EHC Needs Assessment
PUPIL DATA
Please
Tick one
Setting Referral
Professional Referral
Parental Referral
Pupil details
Full name:
Date of Birth:
Home Address and
Postcode
Telephone
Number:
Home Language:
Religion:
Male
Female
Education Setting:
(If Early Years please
state which branch
where applicable and
telephone number):
Year Group:
Headteacher /
Contact name if
Early Years setting
SENCo:
Is the pupil Looked After (LAC)? If yes, please complete the following:
LAC by which
Local Authority:
Social Worker’s
name:
Address details of
responsible
Authority:
Telephone:
Email:
Criteria for assessment - Please number which criteria you believe the pupil/young person meets
Cognition and Learning
Communication and Interaction
Social, Emotional and Mental Health
Sensory and/ or Physical
Please continue overleaf
1
Parent/Carer 1
Title:
Forename:
Surname:
Subject to a successful EHC
assessment, can this address
be printed on EHC Plan if it is
decided to issue?
Address and postcode:
Yes
No (please state reason in
comments below)
Preferred Contact numbers:
Email:
Home Language:
*Parental Responsibility?
Relationship to pupil
Yes
No
Mother
Foster carer
Father
Other
– please state:
Parent/Carer 2
Title:
Forename:
Surname:
Subject to a successful EHC
assessment, can this address
be printed on EHC Plan if it is
decided to issue?
Address and postcode:
Yes
No (please state reason in
comments below)
Preferred Contact numbers:
Email:
Home Language:
*Parental Responsibility?
Relationship to pupil:
Yes
No
Mother
Foster carer
Father
Other
– please state:
Comments
Additional details
Is either parent a member of the Armed Forces?
Yes
No
* Please Note: paperwork will only be sent to Parent/Carers with parental responsibility.
2
REHC 2
PARENT CONSULTATION
Part 1 – To be completed by the school in partnership with the parents/guardians
Pupil’s name:
D.O.B
What language should be used in documents sent to parents:
Please describe any other access requirements (e.g. access to the written word, use of telephone,
sign language, ability to attend meetings, etc.):
The process of EHC Needs Assessment has been explained to parents
Yes
No
Parents have received the Guidance for EHC Needs Assessment (A
guide for parents and carers):
Yes
No
Parents have received information about SEND IAS and Independent
Supporters:
Yes
No
3
REHC 2a
PARENT CONSENT FORM
To be completed by the persons with parental responsibility
Pupil’s name:
D.O.B:
I agree with the decision to refer my child for an EHC Needs Assessment and agree that the Local
Authority may proceed with the assessment if this is appropriate.
I also agree that the Local Authority may consult with other professional bodies that have had any
involvement with my child in the past or present.
This will / may include:
Inclusion/Intervention Specialist Teachers/Workers
Youth Offending Team
Physiotherapy
Occupational Therapy
Speech and Language Therapist
Educational Psychologist
Community Paediatrician
Educational setting
Social services
Children and Families Practices
To decide whether or not to proceed with an EHC Needs Assessment and then whether to issue an
EHC Plan, the request will be considered at the Inclusion and EHC Panel. The Panel is made up of
representatives from Local Authority, Schools/Settings, Health and Social Care.
I agree with my child’s information being shared and discussed at the Inclusion and EHC Panel.
Signature: ________________________________ Date: _________________
Print Name: _____________________________________________________
Relationship to child: _______________________________________
4
REHC 2b
PARENTAL VIEWS
Pupil’s name:
D.O.B.
Please provide information under the following headings:
Tell us about your child/young person’s education and family background:
What is important to us:
How to support us as a family:
What’s working well for your child/young person?
What we want in the future for our child/young person (think about 1 year, 5 years,
adulthood)
5
Please continue overleaf
RECH 2c
MEDICAL / HEALTH INFORMATION AND CONSENT FORM
NB: It is important that this form is returned as the assessment cannot proceed without your
consent to obtain medical information.
Pupil’s name:
Male
Female
Address:
Tel No:
D.O.B:
GP :(name & address)
Tel No:
Please give details of health professionals who can provide information about your child’s
health or development:
Please indicate where seen (i.e.
Still
Approximate
Health Centre /Hospital)
Professional
Name of Professional
involved Date of Last
If outside Milton Keynes please add
address where professional is seen
?
Contact
Yes
Paediatricians*
No
Clinical
Psychologist /
Psychiatrist
Yes
Occupational
Therapist
Yes
No
No
Yes
Physiotherapist
No
Speech &
Language
Therapist
Yes
Other Medical
Specialist
Yes
No
No
Please note that the Community Paediatrician may refer your child to other medical specialists as part
of their assessment. This may happen prior to the Community Paediatrician appointment e.g. hearing /
vision test by school nurse. If your child is currently seen by a Community Paediatrician, an
appointment may not be required. It can take time to obtain information from specialists, especially
outside of the area. Consent in obtaining this information and for sharing it with others is required.
Please complete the lower section.
*If this referral is for a young adult 18 and over then please provide their GP name and address.
CONSENT: I give consent to the health professionals involved, in obtaining and providing relevant
information on my son / daughter or myself as part of the Request for EHC Needs Assessment.
Signature of person with parental responsibility or young person over the age of 18:
…………………………………………………………………….Date……………………………..
(PRINT FULL NAME): ……………………………………………………………………..
6
REHC 3
Have your say!
Name:
Things I want you to know about me:
7
Who I live with:
What people like about me and think I’m good at:
What is important to me:
8
The things that are going well
for me:
The things that I find hard:
How to help me:
9
In the future I would like:
Please indicate when completed by the young person or if it is from
observations and or interviews.
Please refer to the booklet on gaining children and young people’s views
10
REHC 4
SUMMARY OF CONSULTATIONS WITH OUTSIDE AGENCIES
Please indicate current and past involvement with outside agencies
Still
involved
Involved
in past
Date last
seen
Adult Consultants / Clinical Psychologist
Adult Services
Audiologist
Children and Family Practices
Children’s Social Care
Community Paediatrician
Department of Child & Adolescent Psychiatry
Educational Psychologist
Health Visitor
Occupational Therapist
Physiotherapist
Inclusion/Intervention Specialist
Teacher/Worker
Sensory
Speech & Language Therapist
Youth Offending Team
Other…..
If professionals seen outside of Milton Keynes please state address:
Professional
Address
Remember, parents and young people may receive copies of this information.
Please do not submit the following documentation:

Confidential information such as Child Protection Case Conference notes, or professional
correspondence without appropriate permission.

Details which could be unhelpful or damaging to the child or young person’s interests.

However, minutes of relevant meetings e.g. TAF, PSP can be included.

The originals of the above documents are required for your school files.
Recent reports only please (usually not more than 12 months old) with summary of relevant
historical detail.
11
REHC 5
CURRICULUM ATTAINMENTS – PRIMARY/SECONDARY/COLLEGE
Subject
Levels at Anticipated
time of
End of
statutory
year
assessment
Target:
request
Date:
Year
Group:
Previous three terms
Term:
Term:
Term:
Where appropriate
last two years,
end of year
attainment data
Year:
Year:
English
Maths
Reading
Writing
Speaking
Listening
Numeracy
PSHE
Please explain your school’s assessment criteria:
Please provide a list of education settings that the child / young person has attended. (Please explain
any gaps in education)
Has the young person ever been permanently excluded if so when and from what setting?
Please provide how many fixed term exclusion has the child / young person had this academic year
and the reason(s)
If at post 16 provision what qualifications has he / she achieved before coming to college?
You may also wish to attach any relevant examples of work produced by this pupil.
Signature _________________________ Designation _________________________
Date _______________
12
EYFS Progress Tracker - CURRICULUM ATTAINMENTS – FOUNDATION STAGE
REHC 6
Child’s name: ________________________________________ D.O.B: ____________________Setting:______________________________________
40
60
+
3
3
3
3
3
3
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
30
50
3
3
3
3
3
3
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
3
3
3
3
3
3
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
3
3
3
3
3
3
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
3
3
3
3
3
3
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
3
3
3
3
3
3
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
22
36
16
26
820
011
Making
Self-
Manage
Moving &
Health &
Relations
confidence &
Feelings &
Handling
Self-care
Self -
Behaviour
Speaking
Listen and
Understanding
Reading
Writing
Attention
Number
Shape
People and
Space &
Community
The World
Tech
Measure
Exploring
Being
Media and
Imaginative
Materials
awareness
Personal, Social and Emotional
Physical
Communication and Language
Literacy
Maths
Understanding the World
Expressive Arts &
Design
1 = Emerging
2 = Developing
3 = Secure
13
REHC 7
SETTINGS RECORD AND EVALUATION OF ACTION
Date on which setting first identified the child / young person as having additional needs and
support was put in place:
Please can you summarise the child / young person’s strengths and challenges below:
Communication and Interaction
What can name of Child / YP do well and what has he / she achieved?
What does name of Child / YP find difficult?
What we would like to see for name of Child / YP in the future (think 1 year, 5 years,
adulthood)
Cognition and Learning
What can name of Child / YP do well and what has he / she achieved?
What does name of Child /YP find difficult?
What we would like to see for name of Child / YP in the future (think 1 year, 5 years,
adulthood)
Social, Emotional and Mental Health
What can name of Child / YP do well and what has he / she achieved?
What does name of Child / YP find difficult?
What we would like to see for name of Child / YP in the future (think 1 year, 5 years,
adulthood)
14
Sensory and / or Physical
What can name of Child / YP do well and what has he / she achieved?
What does name of Child / YP find difficult?
What we would like to see for name of Child / YP in the future (think 1 year, 5 years,
adulthood)
Looking at Milton Keynes Guidelines for EHC Needs Assessment, please ensure that you
have completed and attached evidence as requested under one or more categories of need.
Signature: ………………………………… Role: …………………..
Print name
Date
15
ASSESS, PLAN, DO, REVIEW SUMMARY OF INTERVENTION AND SUPPORT
REHC 8
Please record under separate categories of need what intervention and support has been implemented, whether or not it is the primary focus, and what has
worked or not for the last two terms. Please consider the advice in the Graduated Approach to SEND document and evidence how this has been applied.
Please describe what additional resources have been used and how:
Category of Need:
Intervention and Support
Evaluation and Progress
Add more categories if required.
Please also enclose the EHC Needs Assessment Guideline checklist with additional evidence as indicated.
16
Category of Need:
Intervention and Support
Evaluation and Progress
17