SISS Autism Team - Request for Support Form.
Please send this form, with the required evidence attached via email to:
Send0-25businesssupport@solihull.gov.uk
	Evidence Provided

(Please tick yes/no)
	
Pupil Name: 

Date of Birth:
			
Does the pupil have a Diagnosis of Autism?
	Yes
	No 	
Please attach a description of the specific barrier to learning currently being experienced e.g. what is your main concern that you would like support with?
	Yes	No	
Please attach evidence of following the Graduated Response. 
Show your current provision at Universal, Targeted and Higher Needs, (following the Solihull banding advice and Autism specific strategies). 
This is your Assess – Plan – Do – Review cycle.

Example: 
1-Evidence of an observation carried out by SENCO/Lead for Autism following concerns raised
2- Strategies implemented following observation using universal/targeted approaches
3- Description/evidence of impact - what impact did this have on the child when used consistently for a period of time?
	
Yes

No

	
Please attach evidence of a Needs Based Plan, or One Page Profile, that identifies the pupil’s strengths / areas of need, and how best to support the pupil.
	
Yes 
	
No

Evidence of on-going parent and school communication through partnership work e.g. most recent minutes from TAF/TAC meetings / regular SEND meetings with SENCo.  	
Yes

	
No
	
Number of Exclusions (Fixed Term and Internal), if applicable. 	

Reduced timetable documentation, if applicable.	Yes 
	No
	
Reintegration Plan, if applicable. 	Yes
	No	
School has parent permission to make the request for support and share information with the Autism SISS Team.
	
Yes	
No	
Completed copies of the Teachers’ Views and Parents Views, from the ‘All about Me’ tool, completed and returned with this form. 	
Yes	
No 	
Name and role of person making this request:

Name of school or setting:

Date of request :

Teacher / Parent View (please delete as required)

A copy to be completed by teacher and a copy to be completed by parent. Return both completed copies with the Request for Support form. 

Name of Pupil_____________________                            School/ setting_______________________

1
Find it very difficult 	2
Find it quite difficult 	3
Find it ok 	4
Find it quite easy 	5
Find it very easy 	

Area 1 – How easy or difficult does the pupil find communication 
	Speaking about their ideas and thoughts	
	Putting their thoughts into writing	
	Starting conversations with people they know	
	Starting conversations with people they don’t know	
	Ending conversations 	
	Understanding what people mean	
	Knowing how much information  to give in an answer to a question 	
	Understanding peoples’ face expressions and gestures	
	Looking people in the eye – eye contact 	
	Listening for long periods  of time 	

Area 2 – How easy or difficult does the pupil find social interaction 
	Recognising their  own emotions 	
	Talking about their own feelings 	
	Recognising how other people may be feeling 	
	Making friends 	
	Keeping friends 	
	Working in a group 	
	Recognising faces 	
	Remembering people’s names 	
	Understanding that they should speak to different people in different ways 	
	Knowing what is expected of them in different situations 	

1
Find it very difficult 	2
Find it quite difficult 	3
Find it ok 	4
Find it quite easy 	5
Find it very easy 	

Area 3 – How easy or difficult does the pupil find social imagination 
	Changing the way they do things 	
	Coping with sudden change 	
	Switching from one activity to another 	
	Predicting what might happen 	
	Imagining something they have not experienced 	
	Doing more than one thing at a time 	
	Making choices 	
	Learning about things they have no interest in 	
	Stopping doing something that are really interested in 	
	Organising themselves 	

Area 4 – How easy or difficult does the pupil find sensory processing 
	Bright lights 	
	Crowded places	
	Loud noise 	
	Certain materials touching their skin	
	Trying new foods	
	Sitting still for long periods of time 	
	Wearing school uniform 	
	Strong smells 	
	Keeping their balance 	
	Blocking out background noise