Special Educational Needs Team, London Borough of Hounslow
Blue Zone, Civic Centre, Lampton Road, TW3 4DN
Tel: 0208 583 2672
Email: [email protected]
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Request to begin a Statutory Assessment for an
Education, Health and Care Plan
This form is to be completed by the school / education / training provider for the child/
young person with special educational needs and disabilities.
Child / Young Person:
Date of Birth:
1. Details of person completing this form
Name of Person:
Job Title:
Name of Education / Training Provider:
Contact number:
Email address:
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Revised October 2016
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2. Child’s / Young Person’s Profile
Name of Child / Young
Person:
Date of Birth:
Gender:
Age:
Primary Language
used at home:
Other
Languages
used in the
home:
Other methods of
communication if
child / young person
is non-verbal:
Religion:
Ethnicity:
Home Address:
Young Person’s
contact no. (if 16yrs
and over)
Young
Person’s email
(if 16yrs and
over)
Over 16yrs: Does the LA need to consider Mental Capacity Act in
relation to this young person?
If yes, please give reason.
Over 16yrs: Who does young person want involved?
Name:
Relationship:
Contact:
Parent / Carer
Name(s):
Relationship to
child / young
person:
Name of Primary
Carer:
Relationship to
child / young
person:
Parent / Carer
Telephone no.
Parent / Carer
Email:
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Does the child / young
person have a Health
Care Plan?
Yes / No
Name of GP:
GP contact no.
GP email:
GP Address:
GP
Commissioning
Authority (if
known):
Has there been an
Early Help
Assessment?
Yes / No
Date of Early
Help
Assessment:
Has the child / young
person been open to
social care?
Yes / No
Dates when
child / young
person was
open to social
care
Is there currently an
allocated worker in
social care:
Yes / No
Is the child / young
person LAC (Looked
After Child)
Yes / No
From:
To:
Contact no.
Mobile no.
Who has
parental
responsibility if
LAC:
Current Education
Provision:
Date started:
Previous Education Placements, if applicable
Start Date
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End Date
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3. Reasons for the Education Provider decision to request a Statutory Assessment:
4. Reason for concern: (tick twice for primary need and once for any additional
needs)
Areas of concerns (please include full details and attach all relevant recent reports
such as Schedule of Growing Skills; Portage Checklist; Griffiths Test etc):
Developmental delay
Physical
Emotional and
behavioural
Visual
Hearing
PMLD (Profound and
Multiple Learning
Difficulties)
Speech and language
ASD (Autistic Spectrum
Disorder)
Social communication
Medical
Learning
Specific Learning
5. Please give details of any interventions/programmes that have been implemented
(E.g. tasks recommended by other professionals, such as physiotherapist or
speech & language therapist and attach relevant reports.)
The Referrer must include details of how the delegated £6,000 funding has been used
to meet the needs of the child / young person including where provision delivered as
part of a group. Details of how the local offer has been used should also be included.
Evidence of how the school has implemented the ‘assess, plan, do, review’ process
and impact over time of the strategies used MUST be provided.
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8. Relevant medical history:
Please give details of any known difficulty with likely medical cause.
Names of Consultants and hospitals the child attends and details of any significant
periods stay in hospital.
Use of medication e.g. for epilepsy
Also please include detailed results of visual and hearing tests if available.
9. Evidence of recent academic attainment:
Please comment on the pupil’s strengths and weaknesses in all areas, and give NC
(or other relevant attainment data) or ‘P Scale’ levels.
English
Listening and
Speaking
Reading
Writing
Mathematics
Using and Applying
Mathematics
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Number and Algebra
Shape, space and
measures
Handling data
Science
Please record any relevant tests for reading, spelling and number:
Date tested
Age at time of test
Name of test
Result
10. Other professionals working with child
Name
Profession
Address
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Contact no.
Email:
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11. Young person’s views and consent (if over 16years)
If young person is under the age of 16years has the request been
discussed with the child?
Yes / No
Views:
Young person consent
Signed:
Date:
12. Parent/carer views and consent
Please indicate if parents have given permission for this request to share information with
relevant professionals and the date and result of discussions with parent(s)/carer(s) leading to
this request.
N.B.: Signature is mandatory for a Statutory Assessment request.
Comment:
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I pay my council tax to
borough.
Signed:
Date:
13. The following supporting information and evidence has been included:
Details of professional completing the form
Signature:
Designation / Job Title:
Date:
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