SEN Inclusion Fund (SENIF) Request Form
Child’s Details
Child’s Name:
DoB:
Click here to enter a
date.
Parent/Carer
Name:
Parent/Carer
Address:
Parent/Carer
E-mail Address:
Child in Care
(CiC)?
Primary Need:
Choose an item.
Parent/Carer
Phone Number:
Choose an item.
If CiC, which Local Authority has responsibility
for the child (leave blank if Kent)?
Your Setting’s Details
Date of Admission:
Name of your
setting:
Ofsted URN:
Click here to enter a
date.
District:
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Stretched funding? Choose an item.
Your setting contact address:
Your setting email address:
Your setting phone number:
Eligible for: Choose an item.
Eligibility Number for extended
entitlement (30hrs):
Primary School expected date of entry:
Choose an item.
Other Setting(s) Details
Name of Childminder, if
attending:
Details of second PVI setting,
if attending two:
Hours attended
(per week):
Hours attended
(per week):
Has a Specialist Nursery place been requested?
Choose an
item.
Choose an
item.
Choose an item.
If you have answered yes to the above question please answer the following three questions otherwise
leave blank
1. Specialist Nursery name:
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2. Start date/expected start date at Specialist Nursery
Click here to enter a date.
3. How many hours per week attended at the Specialist nursery?
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Child’s Attendance, Needs and Support
Attendance Pattern (please note SENIF does NOT fund lunch periods)
Monday
Tuesday
Wednesday
Thursday
Choose an
Choose an
Choose an
Choose an
AM
item.
item.
item.
item.
Choose an
Choose an
Choose an
Choose an
PM
item.
item.
item.
item.
Child’s Needs
Significant difficulties parting from carer
Outdoor play equipment is not used appropriately
A high level of adult support is required for personal care needs
Unable to choose activities independently
Unable to follow instructions in a small group
Speech cannot be understood by adults
Struggles to feed independently
Play skills are repetitive
Struggles with transitions
Requires visual cues to support understanding
A high level of adult support is required to ensure child’s safety
Friday
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item.
Choose an
item.
Frequency
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Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
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Is the family in receipt of DLA for
Choose an item.
this child?
Is the setting in receipt of DAF for this child? Choose an item.
How do you utilise this funding?
Is the setting in receipt of EYPP funding for this child? Choose an item.
How do you utilise this funding?
Is the family in receipt of funding through a Continuing Healthcare Plan? Choose an item.
Essential information in the last 12 months
Previous visit from E&I Team: Choose an item.
Previously discussed at EY LIFT: Choose an item.
Previous visit from STLS:
Choose an item.
Date of last visit:
Date of meeting:
Date of last visit:
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Training
Training course attended
Autism awareness for early years
Down Syndrome
Positive relationships and social development
Prime Importance of Communication & Language
Risk assessments and care plans
Sensory training
SENCo training
Speech day workshop (SaLT)
Supporting 2yr olds with complex needs
Targeted level language training
Other (please supply details):
Please tick
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Date attended
Other Agency Involvement
Please indicate other agency involvement (please tick all relevant professionals)
Additional reports may be required for clarification of need and support.
Paediatrician
Speech and Language Therapy (SaLT)
Early Support
Social Services
Current needs:
☐
☐
☐
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Occupational Therapy (OT)/Physiotherapy
Early Help
Portage
Please specify how the SENIF will be used to support the child?
Declaration
Has parental agreement been sought?
Date:
Choose an item.
Click here to enter a date.
It is the responsibility of the setting to hold the live parental agreement from the PCi2 part of
the EY LIFT Referral form or Portage referral form.
 It is the responsibility of parents to arrange and provide transport for their child to any preschool setting including specialist placements.
Name of setting representative completing the form:
Role:

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