My Support Plan

Type here

Type here

Name: …………………………………………………………

Type here

School: ……………………………………………………….

Type here

Plan Start Date: …………………………………………….
Plan Review Date: ………………………………………….

Type here

Version number: …………

My Team
People in my Family 
Name	Gender 	Relationship 	Address 	Contributed to My Plan 
	Parental responsibility
Y/N	

						

						

Professionals supporting me and my family 
Name	Role	Supporting 	Contributed to My Plan 
	Agency	address/contact details	

						

						

						

My Progress

Details of the curriculum that is being used to measure progress 

Details of student’s attainment 
Area of Learning  	Attainment prior to beginning My Support Plan
	Attainment at review of plan	

		

	

			

	

My Physical and Sensory Needs 	
Please provide details of the young person’s needs.  	

To be completed at the plan writing meeting	To be completed at the Review Meeting	

Outcomes Sought	
Educational provision to meet my outcomes	
Was the agreed support fully implemented?	
Has the outcome been achieved?

				

My Communication and Language Needs 	
Please provide details of the young person’s needs.  	

To be completed at the plan writing meeting	To be completed at the Review Meeting	

Outcomes Sought	
Educational provision to meet my outcomes	
Was the agreed support fully implemented?	
Has the outcome been achieved?

				

My Education and Learning Needs 	
Please provide details of the young person’s needs.  	

To be completed at the plan writing meeting	To be completed at the Review Meeting	

Outcomes Sought	
Educational provision to meet my outcomes	
Was the agreed support fully implemented?	
Has the outcome been achieved?

				

My Social and Emotional Needs  	
Please provide details of the young person’s needs.  	

To be completed at the plan writing meeting	To be completed at the Review Meeting	

Outcomes Sought	
Educational provision to meet my outcomes	
Was the agreed support fully implemented?	
Has the outcome been achieved?

				

Health and Social Care Details (if appropriate)

My Health Needs (including confirmed diagnoses) 	

Diagnosis / Disability 	Diagnosed By	Is medication taken for disability/diagnosis?
Y/N	Is this medication taken during school hours?	

Other health issues 		
Current medical treatment:		
Family health history:
(Give details of family history that may have a direct impact on the family)		

My Social Care Needs  	
Statutory/Legal measures in place:		
Local authority responsible:		
Other plans:		

Personal Details and Consent

Name of Pupil

UPN
NHS Number 
Health Authority 
	Sex	School Year	
	Date of Birth	
Is the pupil a Looked After Child/Young Person?

Yes                        No

Is the young person in receipt of Pupil Premium? 

Yes                        No	Attendance for current term

Actual/Possible 
	
First Language

Parent Carer First Language

	Ethnicity

Religion 

Address 

Telephone Number

Email Address

Please sign below to indicate that you:
•	Have contributed to the development of this plan.
•	Understand the support that will be provided through the plan.  
•	Agree to a photo of the young person being used on the cover of their plan
•	Agree to a copy of the plan being stored in the School’s and Local Authority’s SEN files. 
•	Consent to a copy of the plan being shared with the people listed in the ‘My Team’ section of this plan and with a Local Authority SEN Officer, if necessary.  

……………………………………………………………………Young Person (if appropriate)

……………………………………………………………………Parent/Carer

……………………………………………………………………School representative / Plan author

……………………………………………………………………Date