Children’s Services and Skills Directorate
SEND 0-25 Service

Request Form for the EBSN Team
The EBSN team is a team of Educational Psychologists and Assistant Educational Psychologists from the Community Educational Psychology Service (CEPS).
The team provides bespoke support for pupils who are at risk of Emotionally Based School Non-Attendance.  In order to support this request, please also refer to:
1.	The EBSN Team school request checklist
2.	The EBSN school support pathway
3.	The EBSN request pathway
4.	The guidance ‘Emotionally Based School Non-Attendance’
	
This form can be scanned and emailed. Please return completed forms to:
EBSN Team Requests:: EBSNteam@solihull.gov.uk
If you have any other queries regarding this form please call: 0121 704 6690	
1.	Child’s Details (School to complete sections 1-5)	
Child’s Name: 
	Preferred Name: 		
Address: 

	DOB: 	Male / Female	
	Is this child looked after by local authority? Yes / No	Age: 	
	Year Group:		
	School name:		
2.	Parent/Carer Details	
Please provide full names and addresses (if different) of each Parent/Carer for the child. Please indicate who has parental responsibility.	
A.	Name: 	B. Name:	
Relationship to child: 	Relationship to child:	
Address:

Postcode:
Contact No:
Mobile No:
Email address:
	Address:

Postcode:
Contact No:
Mobile No:
Email address:

3.	Name and details of person making this request:	
Name:

	Contact email and phone number:
	
Designation: 
	Headteachers name: (for our reference only): 

Signature: ……………….….…………………………………………………  Date: …………………………	

4.	Further Information: Does this child/ young person have/ received	
School Support 	Yes / No	EHC Plan / Statement 	Yes / No	

5.	Further evidence detailed in the ‘Referral Checklist’ has been provided                        	
YES/NO	
The following factors will delay the request:
•	Incomplete information provided
•	Inability to authenticate current address and phone numbers
Please Note:
•	Parental Consent: No referral will be accepted without consent

Contact details

Should you have any queries about this form you can contact Dr Louisa Jones, Dr Sofia Hussain or Dr Faye Hingley, EBSN team at EBSN Team Requests, Elmwood Place, 37 Burtons Way, Smiths Wood B36 0UG or email: EBSNteam@solihull.gov.uk