PARENT, CARERS OR YOUNG PERSONS REQUEST FOR A STATUTORY EDUCATION, HEALTH AND CARE ASSESSMENT

Please complete all parts of this form before sending.
If parents, carers or young people are unable to complete this form, they should phone or email the START (Statutory Assessment and Review Team) 0121 704 6690 or email edsen@solihull.gov.uk

DETAILS OF CHILD/YOUNG PERSON	
Child's/Young Person’s Name:	Date of Birth:	
Current Setting/School	NC Year Group:	
Age:		

CURRENT NATIONAL CURRICULUM LEVELS OR P SCALES (If known)	
Maths		
Reading		
Writing		
Speaking and Listening		

Please indicate the primary area(s) of need identified: Please prioritise (1, 2 -
primary/secondary need):	
Cognition and
Learning	Communication
and Interaction	Social, Emotional
and Mental Health	Physical/Sensory/
Medical	
Moderate
learning difficulties		Speech &
language difficulties		Social difficulties		Physical
difficulties		
Specific
learning difficulties		Autistic
Spectrum Disorder		Emotional
difficulties		Visual
impairment		
Severe learning
difficulties		Social
communication difficulties		Other SEMH
(Social Emotional Mental Health) Difficulties		Hearing
impairment		
Profound &
multiple learning difficulties				ADD/ADHD		Medical
difficulties		

REASON FOR REQUEST

Explain the reason for requesting this EHC assessment
You should consider the following areas:

Education and learning - for life and work:	
Communication and interaction:	
Friendships, and relationships:	
Social, emotional & mental health needs:	
Independence:	
Physical, sensory and health needs:	
Support for the family:	

Which of these services has been working with the child/young person?
e.g. Specialist Inclusion and Support Service (SISS)

Name of Professional and contact details	
Date(s) of involvement	Report
included? (Y/N)	
SISS CLD Team (Children
with Learning Difficulties)				
SISS ASD Team
(Autistic Spectrum Disorder)				
SISS SEMH Team (Social Emotional Mental Health)				
Other SISS Team				
Educational Psychologist				
Community Paediatrician				
Speech and Language
Therapy Service				
Paediatric Occupational
Therapy Service				
Paediatric Physiotherapy
Service				
Child and Adolescent Mental
Health Service (CAMHS)				
Other – Please list below				

REFERER	
Name of person submitting the
request		
Address		
Phone		
Email Address		
Relationship to child/ young person:		
Signature		
Date		

PARENT/CARER CONSENT

I/We give consent for the LA to request further info from School.

I/We confirm that I/We have read and understood all of the information included in this request. I/We certify that the information, which I/we have provided, is correct.

I/We understand that the information provided in this application will be used to ensure that the council’s records are correct. It may also be shared with other agencies and service providers to ensure that your son/daughter receives an appropriate service.

Signature of parent/carer……………………….. Date……………………. Signature of parent/carer……………………….. Date…………………….

Return to:

Statutory Assessment and Review Team Learning Skills and Progression  Elmwood Place
37 Burtons Way
Birmingham
B36 0UG