Classification: OFFICIAL-SENSITIVE
SEN Team
Request for Education Health and Care(EHC) Assessment
Date request received by SEND
service
FOR OFFICE USE ONLY
Completion due date
Notes for use: If you are completing form electronically, text boxes will expand to fit your text Where check boxes appear,
insert an ‘X’ in those that apply. Requests must be typed/word processed.
Health Authorities have a statutory requirement to notify Local Authorities about pre-school children who may have Special
Educational Needs. Please indicate if this is a health notification Yes
No √
Identifying details
Record details of child or young person being assessed.
Given name(s)
Male
Legal surname
Female
Previous names
Address
Date of birth
National Curriculum
Year
Example: FS1
UP Number
Contact tel. no.
Postcode
Ethnicity
White
Black or Black British
Asian or Asian British
Mixed/Dual Background
Chinese & Other
White British
Caribbean
Indian
White & Black
Caribbean
Chinese
White Irish
African
Pakistani
White & Black
African
Traveller of
Irish Heritage
Any other
Black
background*
Bangladeshi
White & Asian
Any other
ethnic group*
Any other Asian
background*
Any other Mixed
background*
Not given
Gypsy/Roma
Any other
White
background*
*If other, please specify
Immigration status
Child’s first language
Parent’s first language
Is the child or young person
disabled?
Yes
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No
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If ‘yes’ give details
Example: Communication difficulties, Social Interaction difficulties, Specific diagnosis
Details of any special requirements
(for child and/or their parent) eg signing,
interpretation or access needs
Example: Dad has limited spoken English. For meetings a Polish speaking
interpreter would be needed
Request Information
Is/has the child or young person been
Looked After?
Yes
Dates
No
Is/has the child, young person or their
siblings been subject to Child Protection
planning?
Has the child or young person been
assessed by early help (old CAF??)?
Yes
Dates
No
Yes
Dates
No
Details of parents/carers
Name
Contact tel. no.
Email
Relationship to child or young person
Address
Who has parental responsibility?
Put both parents’ details if
they have joint responsibility
but live separately.
Postcode:
Name
Contact tel. no.
Email
Relationship to child or young person
Address
Postcode:
Current family and home situation
(e.g. family structure including siblings with dates of birth, other significant adults etc; who lives with the child and who
does not live with the child)
Example:
(CH) lives at home with his parents, an older sibling age ….years and a younger sibling age….
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(CH)s maternal aunty (Mum’s sister) cares for him and his brother every afternoon at her home nearby.
(CH’s) parents are divorced; (CH) lives with Mum Monday to Friday and with Dad Friday night to Sunday night.
Details of person(s) requesting EHC Assessment
Name
Address
If a STePS practitioner is writing the request
with you, put her name in this section along with
yours.
If it is an independent request from you, write
your name and the Nursery/Setting details in
these boxes.
Put STePS address here-Nursery address can
be put in the education section below.
Contact tel. no.
Email
Role
Put both emails here
Organisation
Postcode:
Services working with this child or young person
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Put both contact numbers here
with a name
STePS EIT if they are cowriting request along with
your setting (PVI nursery
or playgroup)
Univer
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GP
Details
Name and Address
Tel.
Early years/education/FE
training provision
Details
Write Setting name and address
here if co-writing with STePS
practitioner.
If making request independently
write above
Tel.
Early Intervention Practitioner
Educational Psychologist
Teacher for Children with Visual
Impairment
Tel.
Service
This could be one or
more professionals
from STePS team
Details
Other services
Write each person’s details in
separate box;
Name
Role
Base
Contact details
Service
This could be one or
more professionals
from Health Team
Details
Speech Therapist
Community Paediatrician
Health Visitor
Community Nursery Nurse
Tel.
Service
This could be one or
more professionals
from Social Care
Details
Lead Professional
Social Worker
Tel.
Service
This could be workers
from support groups
Details
Umbrella
Home Start
Tel.
Please append any reports and/or assessments that have been completed and which provide
evidence to support this application. Note in the body of each section if you have enclosed evidence
Summary of strengths and needs
Consider each of the elements to the extent they are appropriate in the circumstances. You do not need to comment on
every element. Wherever possible, base comments on evidence, not just opinion, and indicate what your evidence is.
1. Development of child or young person
Has the child received routine school health surveillance
Health
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not applicable if child not school age
Classification: OFFICIAL-SENSITIVE
General health
Conditions and impairments; access to and use
of dentist, GP, optician; immunisations,
developmental checks, hospital admissions,
accidents, health advice and information
Example: (CH) is under the care of Community Paediatrician(NAME)
Mum has concerns around (CH)'s general well-being she says he is
very easily sick and that he appears to be constantly tired even
though he sleeps well. Blood tests have come back as normal. (CH)
often has bruises on his body arising from frequent tumbles and his
unsteady balance. He sees the GP if there are concerns around the
severity an injury. (Paediatrician NAME) has requested information
from nursery to help with diagnostic possibilities. (CH) has recently
been seen by Speech Therapy Service. On her visit (DATE) the
Speech Therapist was unable to carry out adequate assessment
due to (CH)'s non-compliance therefore she plans to observe him at
nursery shortly –(DATE) According to development assessments
carried out at nursery (DATE) CH) is showing a delay in all areas of
his development, particularly around communication, speech and
language, social interaction and play skills His progress has
plateaued according to his most recent assessment review (DATE)
see development profile attached. He appears to be functioning
around half his chronological age, less in some areas.
CH) has been prescribed glasses to wear but he is very reluctant to
wear them
Physical development
Nourishment; activity; relaxation; vision and
hearing; fine motor skills (drawing etc.); gross
motor skills (mobility, playing games and sport
etc.)
Example: According to Mum (CH) has had his hearing checked and
there is no concerns. He is prescribed glasses to wear.
Observations from nursery highlight that when standing (CH) tends
to lean forwards resting his body on a surface such as a table or
cupboard. When sitting down on the floor he will lean to one side
and roll himself to get up, he avoids using his hands to aid him. Mum
says he is unable to squat, instead tends to bend over to pick things
up and drops himself down when he needs to get to floor level.
When running he will learn in one direction. He is able to run holding
a ball under his arm, however his legs are splade and stiff.
(CH)'s hand/eye co-ordination is developing with targeted practice;
he is learning to place shapes into a shape sorter and build bricks
into a tower. He shows very little interest in using tools to make
marks and therefore tends to avoid this type of activity; he has good
manipulative skills.
At home he enjoys playing electronic games and pushing cars.
(CH) is developing his skills to spoon feed himself; he is able to
drink from an open cup
(CH) can be very selective in his food choices and therefore has a
restricted diet.
Parents say he sleeps well and in his own bed.
Speech, language and communication
Preferred communication, language,
conversation, expression, questioning; games;
stories and songs; listening; responding;
understanding
Example: CH) has recently had an initial visit from Speech Therapy DATE, further visits are to be arranged in order to carry out a full
assessment. The Speech Therapist has noted in her initial report
(enclosed) that (CH) has an expressive language disorder and has
needs in the areas of attention, listening, understanding and using
language, social communication and interaction and with his play
and inflexibility of thought. According to assessments carried out at
nursery, (CH) uses very limited single word vocabulary with key
learnt phrases such as 'Oh dear', or he recites characters words and
phrases from TV programs, he often echo's back what is said to him.
He will approach key adults and say the word for toilet when he
wants to do a wee and he will pull the staff member towards the door
to indicate wanting to go to the toilet. Mum says he uses just a few
key words at home. (CH) will cry if not understood and he will cry to
express his needs as well as sometimes screaming, throwing
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objects or snatching objects off other children. Sometimes he will
pass an object back to a child as if to share, this is a target that
nursery have been working on with him. (CH) hasn't the ability to join
in or start a conversation; however he has started to enjoy joining in
with actions at song time, where he may sometimes stand on the
peripheral of the group or at a distance watching/listening.
(CH) doesn't make any attempt to communicate interactively with
adults or children. He does not use gesture such as intentional finger
point and distance point at nursery. Mum says he will sometimes
point to what he wants and take her hand to lead her to what he
wants at home. It is difficult to assess his level of understanding as
(CH) tends not to respond to adult directions.
Emotional and social development
Feeling special; early attachments;
risking/actual self-harm; phobias; psychological
difficulties; coping with stress; motivation,
positive attitudes; confidence; relationships with
peers; feeling isolated and solitary; fears; often
unhappy
Example: (CH) is now very settled at nursery after a very stressful
transition period where he would throw objects and hit other children
and be generally upset. He is most happy when left to his own play
routine. He has started to accept his key worker playing alongside
him for short periods; however any approaches she makes to
engage him directly in activities or attempts she makes to extend his
play are often met with very little response or he may just walk away.
Lots of intensive interaction type play is being used to try to develop
his social play and interaction skills. He is not very responsive at all
to other adults at nursery. (CH) prefers to isolate himself from others
throughout the day. He can become very upset with unplanned
changes to routine and Mum says he gets very anxious going to new
places and being with unfamiliar people. Mum says he will show
empathy to her by cuddling her if she gets upset.
Behavioural development
Lifestyle, self-control, reckless or impulsive
activity; behaviour with peers; substance
misuse; anti-social behaviour; sexual behaviour;
offending; violence and aggression; restless and
overactive; easily distracted, attention
span/concentration
Example: (CH) can spend a long time playing with his favourite toys
and he will concentrate on the finer detail of the toy such as the
wheels spinning.
(CH) engages in repetitive play behaviour such as pushing a car
along a surface and he rejects anyone trying to join in at these
times. It is hard to distract him or divert his attention to other
activities. He will walk away if he doesn't want to do something. On
arrival at nursery he will perform the same act which is finding the
car box and tipping out the contents then he goes off to play with a
car. (CH) will stand and throw things if frustrated or upset and he
may run to the door to indicate he wants to go home. He will snatch
objects off other children He is starting to respond to the 'stop'
gesture/ command and can on occasion be distracted when he is
demanding a toy off another child. Mum says (CH) doesn't have any
awareness of danger particularly when out and about and has to be
watched very carefully near roads.
1. Development of child or young person (continued)
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Identity, self-esteem, self-image
and social presentation
Perceptions of self; knowledge of
personal/family history; sense of belonging;
experiences of discrimination due to race,
religion, age, gender, sexuality and disability
Example: (CH) will happily greet Mum when she arrives to collect
him from nursery. He recognises his own image in an individual
photograph and also identifies himself and other familiar children in
a group photograph as well as recognising images of his parents
and family members.
Family and social relationships
Building stable relationships with family, peers
and wider community; helping others;
friendships; levels of association for negative
relationships
Example: (CH) prefers his own company at nursery. His younger
sister attends nursery at the same time; there is little interaction
between them. Mum says at home he likes to run with his older
brother and he loves hugging his Dad.
Self-care skills and independence
Becoming independent; boundaries, rules,
asking for help, decision-making; changes to
body; washing, dressing, feeding; positive
separation from family
Example: (CH) now separates from mum without anxiety when he is
left at nursery after having a very anxious transition period into
nursery. (CH) will take his coat and hat off when he comes into
nursery and will give his coat to his key worker or to Mum. He uses
the toilet independently. He will hold his hands under the tap but
needs an adult to support him with hand over hand prompts to
encourage him to wash them; he will then look to the adult for a
tissue to dry his hands.
(CH) needs prompts to remind him to go to have snack/drink and
encouragement to engage in different activities. Mum says at home
he will open a cupboard to get food. He prefers to engage in self
chosen activities.
Learning
Understanding, reasoning and
problem solving
Organising, making connections; being creative,
exploring, experimenting; imaginative play and
interaction.
Please report on any assessments completed,
National Curriculum levels etc
Example: (CH) is able to recognise a circle and square shape,
identify primary colours and numerals 0-10.
Development profiles show (CH) has delay across all key areas of
his development including low play skills
Refer to Development Profile attached.
(CH) doesn’t show an interest in imaginative play, cars are his
favourite activity but his play will only consist of pushing the car
along a surface back and forth. (CH) will sometimes play in the
water for long periods of time, filling containers and empting them
repeatedly; there is no spontaneous extended play
(CH) finds it difficult to generalise his skills when in different
situations/places.
Participation in learning, education
and employment
Access and engagement; attendance,
participation; adult support; access to
appropriate resources
Example: (CH) has been attending nursery 5 half days a week. (CH)
requires lots of encouragement from adults to join in activities and
when he does his attention and participation is very limited. He can
be very resistant to an adult joining in with his play.
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Support, progress and achievement in
learning
Progress in basic and key skills; available
opportunities; current support being provided
and impact of this.
Please specify amount of support you provide,
individual or small group etc. (timetable)
Aspirations
Ambition; pupil’s confidence and view of
progress; motivation, perseverance
Example: (CH) is toilet trained, he will assist in dressing/undressing
by pulling his trousers down but sometimes needs help to pull them
up. He needs prompts to drink and eat snack.
Additional adult help has had to be put in place to encourage and
support (CH) to access a full range of activities. If he is left to his
own devices he will tend to play only with the car and water activity
in the same rigid play pattern that he enjoys, he may occasionally
play with the building bricks with his play being focused on building
towers. His key worker is using support strategies such as Intensive
Interaction techniques to try and encourage joint play and
interaction; this has inconsistent responses depending on (CH)'s
mood that day. Adult support is needed on a daily basis wherever
there is an opportunity to help him to integrate with other children, to
help him to communicate with them and to help him to learn to form
relationships with other children. When (CH) is in a receptive mood
adults take the opportunity to encourage him to take turns in a
shared activity with themselves and another child to encourage his
social interaction and communication skills. He is encouraged to join
other children at group time and more recently he has on occasion
moved to stand at the edge of the group if the story is motivating
enough to capture his interest. He will watch the other children at
music time and has shown an interest in the musical instruments but
prefers to entertain himself with them rather than join the group
activity.
Adult support is required to guide (CH) through the daily routine, the
adult needs to give him individual instruction and guide him to what
he needs to do; this is often accompanied with visual representation
as well. (CH) is learning to associate objects by their photographs; it
is anticipated that he will eventually respond to using visual cues
and commands such as 'First/then and a visual timetable.
Visual aids such as photographs of family and staff members are
used to help him to learn to associate names with people and
photographs of activities are being introduced to encourage him to
make choices between two activities. He needs an adult to
demonstrate and talk him through these resources and to prompt
him to use them throughout the day.
Child may be happy to show work tasks they have done or they may
be developing skills to work through a task if it is motivated by a
favourite activity/reward. In some cases a child may need lots of
praise through each step of a task to encourage their perseverance
and they may get very despondent if they struggle or the end result
is not immediate.
You could note this here.
Example: (CH) needs adults to encourage him to engage in an
activity when it is not self chosen and the adult may need to modify
an activity if it looks like the task is proving difficult for him, otherwise
he will fast loose interest. He is more motivated to attempt a task if it
is a number related activity.
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2. Parents and carers
Basic care, ensuring safety
and protection
Provision of food, drink, warmth, shelter,
appropriate clothing; personal, dental hygiene;
engagement with services; safe and healthy
environment
Example: (CH) appears well cared for. Mum always provides (CH)
with a drink and fruit and veg every session for his snack as he is
particular about what he eats. Clothes are always appropriate for the
weather, clean and right fit. Mum will inform nursery staff if (CH) is
unwell and will keep us up to date with how he is recuperating.
Parents work very closely with nursery staff to help plan targets and
share information on any concerns, progress and medical
appointments. (CH)’s parents are very supportive on the interventions
and recommendations nursery put in place and try to replicate this at
home. They hope that (CH) will be provided with the appropriate help
he needs to continue to develop his skills when moving onto school.
If you have no information about the home environment then
comment to say so
Emotional warmth and stability
Stable, affectionate, stimulating family
environment; praise and encouragement;
secure attachments; frequency of house,
school, employment moves
Example: Mum is very loving and caring in her approach to (CH) and
he will cuddle her in response. (CH) is very close to his father and he
often cuddles him and is always happy to see him.
Guidance, boundaries
and stimulation
Encouraging self-control; modelling positive
behaviour; effective and appropriate discipline;
avoiding over-protection; support for positive
activities
Example: Parents show they are very committed to helping (CH) to
develop his skills and achieve his potential; they have been working
alongside nursery staff on implementing behaviour management
strategies so there is a consistent approach at home and nursery.
3. Family and environmental
Family history, functioning and well-being
Illness, bereavement, violence, parental
substance misuse, criminality, anti-social
behaviour; culture, size and composition of
household; absent parents, relationship
breakdown; physical disability and mental
health; abusive behaviour
Note here anything relevant
Wider family
Formal and informal support networks from
extended family and others; wider caring and
employment roles and responsibilities
Example: Some family live nearby and have regular contact and are
often round the home visiting.
Housing, employment and
financial considerations
Water/heating/sanitation facilities, sleeping
arrangements; reason for homelessness; work
and shifts; employment; income/benefits;
effects of hardship
Example: Dad is self-employed. Mum looks after the family and
doesn't work externally
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Social and community elements
and resources, including education
Day care; places of worship; transport; shops;
leisure facilities; crime, unemployment, antisocial behaviour in area; peer groups, social
networks and relationships; religion
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Example: Family gatherings are important to the family. The family
are very involved in their local church activities
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Reasons for EHC Assessment
Note here what support systems are needed in the setting to help to meet the child’s needs.
Example:
At nursery this is what is currently needed to be in place to support (CH);
 Having a key person allocated to support him on arrival at nursery to settle him in and to be available at
times when there are changes in the daily routine.
 Having an adult carry out intensive interactive type play several times a day aimed towards encouraging
a positive receptive response to adult direction.
 Having an adult available to guide him to different activities and encourage him to engage in them.
 Having an adult demonstrate how to play functionally with common toys and to encourage him to
participate in new experiences so that (CH) can develop his creative and explorative skills.
 Having structured 1-1 five minute teaching sessions several times a day with an adult to help him practice
his targeted learning programmes.
 Having an adult to guide him through the structure of the day and to encourage him to join in group time
activities by using verbal, gesture and visual aids.
 Having adult support to help him develop his social communication by facilitating peer interaction play in
order to help him to start to form friendships with other children including teaching him what is appropriate
acceptable behaviours.
 Having an adult available at key times to encourage him to develop his self help /independent skills.
 Having close monitoring of his behaviour from adults when he is playing near to other children.
 Speech Therapy targets
 Educational Target Plans
Concerns are that without intensive support plans being available when moving onto school (CH) will make very
little progress in any aspects of his development.

(CH) will need on-going support to help him to continue developing his skills and potential during his
school life. This will include continuation of resources available both internally and externally of school to
specifically support him with developing his speech and communication, social interaction and
relationships with other children, his physical skills, independent skills, play and learning skills.
 (CH) will need identified key adults he can relate to and who have experience in supporting children with
the same difficulties that he has and who have the skills to implement the recommendations from the
health professionals. (CH) may need a specialist provision which can provide for these needs.

It will be vital to his emotional well being that a well planned transition into school is arranged to include
several visits prior to him starting, so that he gets familiar with the adults he will be coming into contact
with and he becomes familiar with school environment.
Desired Outcome
Note here the hopes and expectations you and parents have for the child to achieve in the longer term
as a result of the continuation and provision of services and resources highlighted in the EHC request.
Example: For (CH) to develop his overall skills to enable him to participate confidently, independently and
successfully in a range of school activities and to form friendships with his peers.
By the end of year FS2
For (CH) to have developed his communication skills – receptive and expressive, in a way that will help him to
sufficiently be able to communicate his needs and preferences in a positive way and to be receptive to adult
direction.
For (CH) to have developed his spoken language, to be able to use 2-4 words together, to comment and
converse.
For (CH) to form positive peer relationships and engage in a way that he can manage and is acceptable in small
group and whole group adult led activities.
For (CH) to independently locate activities and the equipment needed for a task – using visual cues if required
For (CH) to participate in a program of adult directed activities (with support if needed)
For (CH) to be confident in using visual aids and accepted other means to help him to communicate and to
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understand what
others are asking of him, including using a visual timetable to help him to work through the
11 daily schedule.
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Parental Consent Form For Request for Education Health and Care Assessment and
Information Sharing between Agencies
We need to collect the information in this form so that we can understand what help your child and family may
need.
We will treat your information as confidential and we will not share it with any other organisation unless we are
required by law to share it or unless you will come to some harm if we do not share it. In any case we will only
ever share the minimum information we need to share.
To do this your consent is required. The professionals or agencies that may be involved in sharing information
are:
Child & Adolescent Mental Health Service Physiotherapists
Children’s Community Nurses
Police
Clinical Psychologists
Portage Service
Community Paediatricians
Psychiatrists
Educational Psychologists
School/Educational Setting
General Practitioners
School Health
Health Visitors
Special Education Needs Team
Hospital Consultants
Specialist Teacher Advisors
Housing Providers
Social Workers
Learning Disability Nurses
Speech & Language Therapists
Occupational Therapists
Transition Operational Group
Parent Partnership
Voluntary Organisations
It is also important that you know that we record information on a database and case
records that we use to help plan the services we provide.
PLEASE COMPLETE THE FOLLOWING:
We will not be able to proceed with this request unless the following has been FULLY completed.
Thank you,
Declaration
As part this request for an EHC Assessment I/we have read and understood the
information above.
I/we give consent to an assessment being undertaken and information regarding our
child and family being shared by and with professionals from relevant NHS Trust,
Derby City Council and other agencies as listed above.
I/we accept that information will be kept on a database to ensure the quality of the
service.
Parent/Carer
Signature:
Date:
Child/Young Person
Signature:
Date:
If at any time you wish to withdraw your consent please discuss with your lead
professional.
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