EHC Assessment Request

Information sharing & data protection Statement

We will use the information in this form to consider whether to conduct a needs assessment under the requirements of the Children & Families Act 2014.

We may also share relevant information on a confidential basis with the Department for Education or other Government agencies and public bodies as required to meet our statutory obligations.

The information that you and other professionals provide will normally be shared with your consent. Examples of situations when we may share information without your consent are:

If we need to find out urgently if a child is at risk of harm or we need to help a child who is at risk of harm.
If we need to help an adult who is at risk of harm.
If we need to help prevent or detect a serious crime.

We have also published a detailed Privacy Notice regarding the information we collect, the purposes for which it is required, and how you can access data we hold about you.

* Please select one of the following

Consent

I understand the information gathered will be stored and used for the purpose of deciding whether to conduct an assessment and/or provide an Education, Health and Care Plan and/or in recommending other services to me.

If there is any individual or organisation who you would not wish information to be shared with, please give details below and a reason why:

* Consent

By ticking this box I agree to the gathering and sharing of information between my educational setting, health services, social care or other professionals as necessary to support the EHC needs assessment and planning process.

1 Details of person requesting an EHCP Assessment

* Has the request come from the young person? (over 16 years)

Preferred spoken language

Preferred written language

Address:

Is this the first request made for the child or young person?

Yes
No
Not known

2 Child or young person's details

* First name

* Last name

Middle name(s)

Preferred name

UPN

Internal system reference

* Date of birth

Age in years

Year Group Not applicable

Year Group Offset

A value of 0 means the child or young person is in their age expected year group.

* Gender

NHS Number

Legal status

Ethnicity

Preferred spoken language

Preferred written language

Main telephone

Email address

Address:

Preferred method of contact

Post

3 Child or young person's main contacts (family and involved professionals)

Full name

Relationship or role

Organisation (if applicable)

Preferred language

Telephone

Address:

Preferred method of contact

Post

4 Details of the child or young person's current education setting(s)

Choose a setting or setting type for a setting?

Setting

Type

Search for a setting within the area

Choose setting type

Additional Details

Please search and select a setting
The setting's details will be displayed here once selected.

5 Important information about the child or young person

What historical information about the child or young person's Special Educational Needs (SEN) is relevant to this request

What historical information about the child or young person's health needs is relevant to this request

What historical information about the child or young person's social care needs is relevant to this request

Was the child or young person involved in the discussion that led to this request?

a

Views and opinions of the child or young person

Has the parent(s) or carer(s) been involved in the discussions that led to this request?

EHC Assessment Request

Information sharing & data protection Statement

Consent

1

Details of person requesting an EHCP Assessment

2

Child or young person's details

Child or young person's details

3

Child or young person's main contacts (family and involved professionals)

4

Details of the child or young person's current education setting(s)

5

Important information about the child or young person

a

Views and opinions of the child or young person

b

Views and opinions of the parent(s) or carer(s)

Draft