Multi-Agency Planning Group Referral Form
Please attach a copy of child’s My Plan+ and review
Please complete this form in line with the EY Process Map for accessing additional resources
Name of Child:
Name of Parents:
Address:
DOB:
Postcode:
Tel No:
Home Language:
Name and Address of Early Years Setting:
M/F
Email address:
Ethnicity:
Details of SEND/Inclusion training attended by staff currently working at the setting:
Training Course Title
Date Attended
Name of Staff
Job Title/Role
1. Please describe the advice, guidance and any interventions that you have already put in place in
order to achieve the agreed outcomes in the child’s My Plan+
Has your EHA been involved?
YES / NO
2. Please list the outcomes that you have not been able to achieve despite the interventions
you have already put in place (copy and paste the outcomes directly from My Plan+)
Outcomes that have not been
achieved
DW/MAP Referral form Jan 2017
What additional support/resources does the TAC feel are needed
for the child to achieve their agreed outcomes (if you are
requesting additional staffing support please include the number
of hours)
3. Have you had any difficulty in engaging with any service/professional you have requested
intervention from (within the setting or completion of Analysis of Assessment form for My Plan+
etc)
Signature of Referrer:
Date:
Signature of Parent/Carer:
Date:
NB: Referrals will not be considered if you do not attach copies of the relevant paperwork
Please ensure the following documents are attached (this will enable
your application to be dealt with promptly)
1. My Plan (plus EP and ATS report, if applicable)
2. My Plan+
3. My Plan+ Review
4. Risk Assessment
Attached (Please tick)
Please return this form to: Denise Webb, Administration Officer, Early Years SEND Service,
Gloucestershire County Council, Shire Hall, Block 4, 3rd Floor, Westgate Street, Gloucester GL1 2TG or
email with digital signature to [email protected]
Re-applying for additional resources:
 Additional resources will be allocated for a specified period in order to meet the agreed outcomes.
 The TAC must review ‘My Plan+’ and the impact of this funding to ensure it is meeting needs and
achieving the agreed outcomes.
 Re-applications must be submitted to the Multi-Agency Planning group with the reviewed ‘My Plan+’
attached.
 An SEND Early Help advisor must attend each review to support the TAC in exploring further
interventions available to meet needs and outcomes.
If referrals are incomplete or do not provide the relevant information
they will be returned to the referrer
If you would like advice and/or support to complete this form please contact:
Ruth Price, SEND Early Help Advisor, Gloucester North, Cheltenham and Cotswold
Mobile: 07796 610496
Kim Nicholls, SEND Early Help Advisor, Forest of Dean and Tewkesbury
Mobile: 07796 610433
Catherine Hardwick, SEND Early Help Advisor, Gloucester South, Stroud and Dursley
Mobile: 07909 937184
DW/MAP Referral form Jan 2017