Consent form for the Early Years Team involvement

The Early Years Team has been asked by the setting/school your child attends to become involved to help with the planning of support for certain concerns and needs. We therefore want to be sure that you understand who we are, what we do, and that your consent is freely given.

The school or setting will have talked to you about the Early Years Team. The Early Years Team is part of Solihull Metropolitan Borough Council’s Education Outcomes and Intervention, Children’s Services Directorate. We are a team of specialist early years practitioners. We provide support, advice, training and information to school nurseries and PVI settings for children with special educational needs and disabilities (SEND) to help make sure that all children are fully included within the setting. The school or setting will share the outcomes of our involvement with you and your child.

As part of our work, we keep electronic records which are held securely and confidentially. These records contain personal information, such as name, and date of birth, plus the details of our work with the child/young person. Since we work alongside other professionals who may also be involved, we would want and may also exchange information with these other practitioners. Please note that any personal data collected will be stored and managed in line with Solihull Borough Council’s commitment to the General Data Protection Regulations. Please visit the privacy statement.

If you are happy for us to work with your child, please complete and sign section 2 of this form. The school/setting will give you a copy of the form and send the original to us.

1. Child/young person’s details (school/setting to complete)	
Child’s name (please print)
	DOB
	
Setting/school
	Setting/School Start Date 	
Home address

	Postcode
	
Is the child a Solihull resident? (please circle)
	Yes/No
	
We have attached evidence of support in setting as part of the graduated response. e.g. a support plan (please circle)	Yes/No
	
Attendance	(please indicate the days and times the child attends)	
	Monday	Tuesday	Wednesday	Thursday	Friday	
AM						
PM						

Child development table

The Early Years Team work with children in a setting who are significantly delayed in at least three areas. This means that they have a delay of 12 months or more for children over 2 years old and 6 months or more for children under 2 years old.

Child development summary
(completed by referrer and supported by other professionals involved where possible)	
Child development summary 2

Child’s chronological age:	…………………..

Please indicate a best fit judgement [x] for the child’s skills’ level in each area based on your observations as represented by the 6 months’ age banding. This will show a child’s area of difficulty and the significance of the developmental delay.

3 to 3 ½ yrs	

	

	

2 ½ to 3 yrs	

	

	

2 to 2 ½ yrs	

	

	

1 ½ to 2 yrs	

	

	

1 to 1 ½ yrs	

	

	

6 to 12 mths	

	

	

0 to 6 mths	

	

	

Represents ‘typical’ development level milestones	
Personal, social and emotional	
Communication and language	
Physical development	
Play	
Independence	

2.	Parent/carers’ details
(to be completed by the person/people with parental responsibility for the child/young person)	
•	I give consent for an Early Years practitioner to become involved. I understand this may involve consultation with staff in the educational setting and other professionals who are involved. There may also be observations and assessments of my child.
•	I give consent for the exchange of information with other services including health agencies who are involved.
•	I understand an electronic file will be opened for my child and that information will be stored securely.
•	I can discuss the purpose and continuation of consent at any time with the Early Years Team.

Name

	Relationship to child

Signature

	Phone contact

Name

	Relationship to child

Signature

	Phone contact

Home address. – please specify which parent or carer if different from child.

Email address

3.	School/setting staff details	
Name

Designation

	Date

The role and purpose of the Early Years Team involvement has been discussed with the parent/carer (please circle)
	
Yes	
No	
Signature

	Phone and email contact information

	

The information on this form will be recorded on a database along with any details relevant to subsequent Early Years Team involvement. These records will be held and used in accordance with the Data Protection Act 2018 and the General Data Protection Regulation 2018. We are compliant with Solihull Metropolitan Borough Council’s privacy notice www.solihull.gov.uk. This information is being collected for the purpose of determining the educational needs of the named child or young person. It may also be shared with other professionals actively involved with the named child or young person, to inform their work. The information collected may also be used for the wider purpose of providing anonymous statistical data used to assist with monitoring provision and/or determining areas of need in order to target future resources.

If the request is agreed, the duration for which consent is given will be shared with the setting, parents/carers and young person. A consent form cannot be accepted and the information will not be held by the Early Years Team if it is more than two months after it was signed and/or if there was no prior agreement with the allocated Early Years Team practitioner.