STATUTORY EDUCATION, HEALTH AND CARE ASSESSMENT
(all boxes on this form will expand as needed)

Name of the person making the request		
Relationship to the child/young adult	SENCo	
If a parent/carer is making the request has this been discussed with your child’s education setting?	N/A	
If you are a young person making this request for yourself, has this been discussed with your school or college ?	N/A	
If a professional is making the request has this been discussed with the child’s parent/carer?	YES	

Education Health & Care (EHC) Needs Assessments/Annual Reviews of Education Health & Care Plans are part of a statutory process under the Children & Families Act 2014, Special Educational Needs & Disability Regulations 2014 and the SEND Code of Practice 2015.  
 
Statutory means that the local authority is required by law to provide a service. This is our legal basis for requesting, obtaining, and sharing information about you or your child. Without the information, we would not be able to provide that service to you. We will always listen to you about any concerns you have about information being shared and will look at how we can respect your wishes but we will need to share information in order to undertake our statutory duties. 
 
Information has to be requested and shared with Education, Health & Social Care colleagues plus other relevant involved professionals for the purposes of an EHC Needs Assessment, and if a Plan is issued, for the duration of the Plan. These will depend on the needs identified but it will always only be for these purposes. 

In the event of formal consultation for nursery/school/college being required, SMBC will share the EHC Plan and associated appendices with relevant educational settings.  If the parental/young adult preference is not the catchment area setting, SMBC will share these documents with the catchment school, and parental preference, as part of the formal consultation process or with any other educational setting that SMBC may consider to be appropriate to meet the special educational needs in the EHC Plan.

If you would like more information about how we handle your data please read the privacy statement in this link 
https://www.solihull.gov.uk/About-the-Council/Solihull-Council-Statement/Childrens-services-and-skills/Special-educational-needs-and-disabilities

Please sign the declaration below:
I give consent for information to be shared as above for the purposes of the assessment and, should an EHC Plan be issued, for the duration of the Plan in order for the local authority to undertake their statutory obligations.

Where a young adult is aged over 16, the local authority requires their signature.

Parent/carer’s consent/Social Worker with PR if CLA  (required for all under 16) 	
Signature	This section must be completed before submitting the application	
Name		
Relationship to the child		
Date		
Young Adult’s consent (required if 16 or above)	
Signature 	N/A	
Name	N/A	
Date	N/A	
The local authority are changing the way in which correspondence is shared with parent/carers. Most letters and documents are now shared via email. This means you get correspondence faster than you would via post.
	
Do you give consent for the local authority to share documents and letters with you via secure email?		

The decision to conduct an EHCP assessment is taken in Solihull Metropolitan Borough Council by a multi-agency panel. From September 2022 there will be an observer from Solihull Parent Carer Voice on this panel – if you DO NOT wish for this parent to be present when your case is discussed please tick this box ☐

Part 1: PERSONAL DETAILS 

Details of the child or young adult	
*Surname	Smith	*First name	Bob	
Middle name(s)	Bob 	*Preferred name if different 		
*Date of birth (dd/mm/yy)	15/06/20	Gender
Identifying Gender if different from above	Male	
Ethnicity	Mixed Raced	Religion	Roman Catholic	
Home language	English	*NHS number (on clinic letters or in Red Book)		
*Email address	example@gmail.com	*Telephone number		
*GP details: 	GP Practice, 93 Dr Lane, Shirley, Solihull, B90 3LA	*Preferred method of contact	Telephone	
*Home address	13 Example Road, Shirley, Solihull, B90 3LA

*Main contacts (those with Parental Responsibility) or the nominated contact for a YP 16 or over if want information sent to someone else..	
*Name(s)	Jane Smith	*Relationship to child/young adult	Mother	
*Home language	English 	*Preferred method of contact	Phone	
*Email address	example@gmail.com	*Telephone number		
*Home address	13 Example Road, Shirley, Solihull, B90 3LA

*mandatory boxes 

Other key information	
Is this child/young adult subject to any of the following?	
	Yes/No	Dates/Authority	
Looked after/care leaver	No		
Adopted/Special Guardianship Order (SGO)	No		
Section 47 – Child Protection	No		
Section 17 – Child in Need	No		
Early Help	No		
Child of Armed Service personnel	No		
Youth or Adult Custody 	No		
Continuing Care Package	No		
Name of current nursery/school/college 	Nursery/school name	
Description of main presenting need	
Please indicate the main category of need (as set out in the SEND Code of Practice)

Communication & Interaction e.g ASD, SLCD 
	
x	

Cognition & Learning 
e.g. learning disability, dyslexia 

Social Emotional & Mental Health 
e.g behaviour, anxiety

Sensory and/or Physical 
e.g hearing or visual impairment	

Details:
	
Choose the main presenting category of need above. You can detail other needs in your description below. Be really clear on what the child’s needs are. Example:

Bob’s main area of need is communication and interaction. However, Bob has significant delays and difficulties in all four broad areas of need. Bob’s needs can be summarised as follows: 

Communication and Interaction

•	Despite implementing strategies over the past 13 months, Bob continues to have sustained difficulties within Communication and Language and the gap between him and his peers is widening.  
•	Bob is predominately non-verbal. He makes sounds, says some single words, but does not use speech for functional communication. 
•	Bob has recently started to use some echolalic or learnt phrases, but not for functional communication.
•	Bob loves songs, and will often sing these.
•	Bob communicates his needs through behaviour, he will scream, throw himself to the floor and repeatedly bang his forehead on furniture, or the floor, if he doesn’t like something, want something, or is frustrated. 
•	Staff must often anticipate Bob’s needs by his behaviours.
•	Bob will occasionally follow simple, routine instructions with visual prompts (such as objects of reference) and 1:1 adult support to lead him by the hand, but this is limited and not yet consistent. 
•	Bob does not follow simple instructions, despite high levels of adult support and visuals.
•	Bob exhibits difficulty in actively listening to and giving any attention to adults and peers. 
•	Bob is engrossed in his own interests and shows little interest in interacting with his peers/other children. 
•	He does not consistently respond to his name and his eye contact is brief. 
•	Bob is beginning to initiate interactions with adults, he is increasingly taking/leading an adult by the hand to what he wants.

Cognition and Learning

•	Bob has difficulties accessing the resources and toys within the pre-school/nursery environment. He becomes quickly frustrated and dysregulated with toys and equipment and requires a high level of adult support to engage in simple play, i.e. building a tower.
•	Bob’s play is solitary, repetitive and exploratory; Bob likes to drop/throw/bang toys and explore objects by licking and mouthing. 
•	Bob’s attention is brief and fleeting; he tends to flit between toys and activities focussing for up to 30 seconds on objects of interest.
•	Bob will focus for longer periods on his main interests independently, which are pushing a vehicle back and forth whilst watching the wheels, and water play. 
•	Bob cannot join in group learning times with his peers.
•	He is self-directed and does not consistently attend to adult-initiated activities, or group learning. 
•	Bob joins a small group ‘Attention Bucket’ session with a high level of adult support (1:2).
•	Bob sits on the carpet for group time when supported by an adult, but is not yet accessing group learning.
•	He is currently accessing a bespoke and highly adapted EYFS curriculum.
•	Bob shows sustained delay in learning across prime areas of EYFS. The gap is widening between Bob and what is expected of him at this age and stage, despite interventions and support suggested by the professionals involved. 

SEMH

•	Bob has sustained difficulty in managing and regulating his emotions.
•	He quickly and frequently becomes dysregulated; he will scream, kick, throw himself to the floor and repeatedly bang his forehead on furniture, or the floor, if he doesn’t like something, want something, or stopped from doing something that he wants.
•	Bob shows no interest in his peers or other children, he is usually in his own bubble.
•	Bob engages in intensive interaction sessions for a brief period (1-2 minutes) he will notice when adults copy his sounds and will smile and make more sounds/he will listen to and copy back adult’s sounds and actions.
•	He has no understanding of sharing or turn taking and will grab/take toys from/lash out at others. He cannot adapt his play to others. 
•	Bob is self-directed during his time in setting.
•	Bob persistently lacks the ability to risk assess his own safety; he requires high levels of support to help co-regulate and to prevent injury to himself.
•	Bob lacks the ability to risk assess his own safety; he climbs on tables, up shelving units and furniture. 
•	Bob does not understand the boundaries of where he can and cannot go and will frequently attempt to abscond into different classrooms and areas of the school. He requires high levels of support at all times to ensure his safety.
•	At lunch times, Bob will grab/take food from other children’s lunches. He will frequently attempt to leave the nursery outdoor area during play and lunchtimes. He requires a high level of adult’s support during this time.
•	Bob has high levels of adult support at all times, including social times, in nursery to keep him safe and to provide an adapted routine and curriculum.
•	Bob is showing sustained difficulty in using and reading non-verbal cues. 
•	He does not follow the social cues of his peers. Bob shows very little interest in his peers, if other children attempt to initiate communication with Bob he does not respond.
•	He is working significantly below age-appropriate levels of development for PSED within the EYFS despite ongoing interventions and the support of professionals.

Physical and/or Sensory

•	Bob frequently seeks sensory experiences such as water and sand, putting non-food items in his mouth. He can become over stimulated whilst playing for extended periods which can result in Bob becoming dysregulated and experiencing an emotional meltdown.
•	Bob frequently seeks to throw objects and toys, repeatedly.
•	Bob will require highly structured and individual play and learning with sustained and significant intervention from the adult with sensory breaks.
•	Bob frequently rocks vigorously back and forth, both when seated and standing.
•	Bob requires regular individualised sensory input to help regulate his emotions.
•	Bob loves to explore objects by touch.
•	Bob is restrictive in his eating; he will often eat very little at lunch times and needs an adult to encourage him to eat; staff often must provide opportunities to ‘graze’ throughout the afternoon to ensure that Bob has eaten.
•	Bob frequently mouths/licks/puts toys and small objects into his mouth. 
•	Bob frequently sensory seeks through biting toys/objects/people around him. He requires a high level of support to redirect him to sensory alternatives.

Part 2: PROFESSIONAL INVOLVEMENT 

Please list any relevant professionals that have assessed or been involved with this child/young adult and their contact details where possible. Include copies of any reports to help us with our decision making.	
Service	Named professional and email address	Tick if seen in the last year	Tick if a report is attached	Tick if a referral has recently been made/the child/YP is on a waiting list 	
Early Years Team 
	Name of Area SENCo and/or ISP – please note Early Years Team is a different service to SISS		 attach any reports you have		
SISS Service
	Is the child known to SISS? i.e. Autism Team – give details if they are		 attach any reports you have		
Child & Adolescent Mental Health Service (CAMHS/SOLAR)					
Adult Mental Health Service					
Educational Psychologist
					
Medical professionals/ health professionals (e.g. Paediatrician, Health Visitor, School nurses, Community LD Nurse)	Give details of Health Visitor, GP, Community Paediatrician		 attach any reports you have		
Occupational therapist
					
Physiotherapist
					
Speech & language therapist	Name the speech and language therapist if known – if referred and awaiting appointment, add this here		 attach any reports you have		
Social Worker
					
Other
	include any other professional involved with the child here e.g. play therapist, SENTAA		 attach any reports you have		

Part 3: CHILD/YOUNG PERSON & PARENT/CARER VIEWS 
To be completed by, or with, parent/carers/young person

Child’s/Young Person’s History (please provide a brief history. You may wish to think about health, eating/sleeping, developmental milestones, social skills and relationships, attitude to school, taking part in activities in and out of school)

Examples of what could be included in this section are detailed below – these are examples and you do not need to include everything if it is not relevant to the child. This section is to be completed with the parent/carer and if relevant the child.

1. Key Points
What are the key educational needs of your child?
How can your child’s needs be met – i.e. what support do they need that is different from or additional to what is usually available for all children?
What are their primary social needs – can they play with others, do they understand sharing, are they anxious in new social situations?
2. Family Life
Who are your family members and who lives in the same household?
Do the other family members have SEN or their own individual needs?
Which family members have regular contact with your child?
Who helps to care for your child?
How do your child’s needs affect the family as a whole?
Are there any events or instances where your child might have been impacted by a family event?
3. Early Years
Pregnancy
Birth – was your child full-term/premature (how many weeks?), were there any complications at birth?
Behaviour as a baby and toddler
When did you start to have concerns about their development?
Any significant events i.e. regression in development (was speaking but stopped) etc.
Help and advice you received and acted upon (Advice from speech and language, community paediatrician, Early Years Team, SISS etc.)
Behaviour in early years education setting (nursery/pre-school)
Major life changes and/or trauma (loss of a loved one, house move etc)
4. Current & Progress
What are your child’s skills and strengths
What is your child struggling with or finding difficult
What you think your child’s special educational needs are
How is your child progressing at school/nursery
How well is your child keeping up with their peers
Your child’s speaking and listening skills
Is your child curious and interested in things
Does your child like to take part in activities at school and at home
How do you feel as a parent or carer
Do you worry about what may happen to your child when they’re at school
5. Friends & Relationships
Does your child have other friendships
Do they get invited to school friend’s parties
How is your child around other adults, such as family friends
Does your child bond well with their siblings
Do they cooperate well and respond to requests
How are your child’s moods
What’s going well with friends and what’s going badly
5. Mental & Physical Health
General health – illnesses or disabilities
Physical skills – walking, motor skills, writing
How well does your child eat, sleep, play
Does your child dress themselves and go to the toilet unaided
What self-care can they do independently? What do they need help with?
Is your child aware of the danger they pose to themselves, others, or any danger they may be in
Is your child empathetic and understanding – do they notice and understand when another child is sad/upset
What are your overall views about your child’s health?

	

The views, interests and aspirations of the child/young person	
•	How do they give their views and communicate?
Is the child verbal? Do they communicate through their behaviour/use of visuals/gesture? Even if a child does not speak, it is highly likely that they still communicate in some way.
•	What are their interests and what do they like doing?
e.g. Bob enjoys being outside and exploring. Bob loves to empty the toy boxes at nursery. Bob will often enjoy holding on to an item at nursery and will carry that around with and use it to bang or glide off other surfaces. Bob loves to explore items by putting them in his mouth.
•	What is important to them?
e.g. Clear and familiar routines are important to Bob. Having time each morning to run outside. Always being able to hold a particular toy. 
•	What do they dislike?
e.g. Bob is not keen on playing alongside others and would much rather play alone in isolation. He does not like sitting down. Bob does not like people being in his personal space this can make him very frustrated. 
•	What do they want to achieve/learn to do/be better at?
e.g. Bob would like to be able to communicate his needs to those around him. Bob would like to ride a bike; he tries hard to push the pedals with his feet.
•	What are their aspirations for the future?
e.g. To be able to make choices. To be able to follow instruction and understand routine. To be able to communicate needs. To become toilet trained. To play with toys in nursery. 
•	What are they good at?
Bob is good at climbing and throwing items. Bob is good at jumping and enjoys bouncing and running. 

Parents/carers views and aspirations for their child’s future	
•	What are your future aspirations for your child? e.g. to be as independent as possible, to have a job, to make friends, to live a full and happy life.
Please note this is what parents want, not setting
•	What support do they currently get and what is the impact of this? 
What support in setting i.e. 1:1 suppport, family support, respite care, DLA funding etc.
•	What are your reasons for making the request for a Needs Assessment and what support do you think your child needs that they are not currently getting? 
Why do parents want an EHC Needs assessment? Do they think the child needs a higher level of support than currently getting? Are they hoping for a place in Specialist Provision?
•	What difference do you think having an EHCP will make to your child?
Again this is the parents view – not setting	

Part 4: EDUCATION INFORMATION – to be completed by school, college or other learning provider

Parent/young adults should not complete the education section if they are submitting this request independent of the education provider.

Details of the educational establishment	
Name of requesting professional	SENCo name	Setting name		
Role 		Setting address		
Telephone number		Email address		
UPN		School/college/learning provider number		

Please complete the section relevant to the child/young person. It is vital that attainment and progress data is included with this request. 

For Early Years: (please refer to the Early Years info on the Local Offer for further guidance) 

We have listed a set of common developmental ‘bandings’ to summarise a child’s skill level in age bands (0-6 months, 6 -12 months etc) which use the settings observation assessment but convert this into a common language for the purpose of EHCP requests. Please indicate the best fit band which the child demonstrates. You may also have other standardized assessments you can use to complement this summary which can be added to the further information box..

	Attainment 	
	Complete this section for EYFS children
Please give results from any developmental or standardised assessments	
Date of assessment	Date of most recent assessment data 	Assessment completed by	Name of SENCo/practitioner/teacher who completed assessments	
Chronological age at time of assessing	Age of child when the assessment was completed 	Assessment information (further information)	What was used to complete the assessment i.e. Solihull EY SEND Assessment Toolkit 	
To evidence progress please add a previous summative assessment 	Age:
Age of child when a previous assessment was completed i.e. 6 months earlier

Date:
	Assessment information (further information)	What was used to complete the assessment i.e. Solihull EY SEND Assessment Toolkit	
Current area of development – mark the development range which best fits the child for each area of their most recent assessment summary		
Solihull summative development bands	Communication and Language Development	Personal, social and emotional development	Physical development 	Literacy Development	Mathematics development 	
Early Learning Goal	Early Learning Goal is a developmental level so do not tick this box unless they are working at this level					
48-60m						
24-36m						
18-24m						
12-18m						
6-12m						
0-6m	 On this table, tick in the correct age band to show the child’s current levels – you do not have to show progress if none has been made, you are showing a true picture of the child’s levels					
Previous Assessment	Communication and Language Development	Personal, social and emotional development	Physical development 	Literacy Development	Mathematics development 	
Early Learning Goal	Early Learning Goal is a developmental level so do not tick this box unless they are working at this level					
48-60m						
24-36m						
18-24m						
12-18m						
6-12m						
0-6m	 On this table tick in the correct age band to show the child’s levels at their previous assessment					

Attainment		
Complete this section for Key Stage 1, 2 and 3 pupils
Please give results from any developmental or standardised assessments		
Year group	
	Assessments completed by			
Subject	Date of assessment	Chronological age at time of assessing	Assessment used	Level	Age equivalent	Progress over last 2 yrs 	
Reading							
Writing							
Spelling							
Maths							
Science							
Please add any additional standardised testing undertaken
Where there is a specific area of need, e.g communication & language/SEMH/Visual or Hearing impairment – please list any specific tests and results. 

N/A – this section is for children in Key Stage 1 and above – go to current support section

		

Attainment	
Complete this section for Key Stage 4 and Post 16 students
Please give results from any developmental or standardised assessments	
Year group		Assessment completed by		
Subject	Date of assessment	Chronological age at time of assessing	Assessment used	Level	Age equivalent	
Literacy ( reading and comprehension) 						
Numeracy						
Details of qualification working towards or gained	Subject	Qualification, e.g. Entry level/GCSE/Functional skills/ASDAN	Predicted or achieved grade	

				
				
Please add any additional standardised testing undertaken
Where there is a specific area of need, e.g communication & language/SEMH/Visual or Hearing impairment – please list any specific tests and results. 

	
Details of work related experience/learning, e.g. vocational courses/work experience placements	

	
Please record here the progress and development over the last 2 academic years including towards the PfA outcomes. 		

Current support
SEND CoP 6.63 says: Where, despite the school having taken relevant and purposeful action to identify, assess and meet the SEN of the child or young person, the child or young person has not made expected progress, the school or parents should consider requesting an Education, Health and Care needs assessment. To inform its decision the local authority will expect to see evidence of the action taken by the school as part of SEN support.

The SEND CoP also says the LA can ask for APDR evidence of this support. 

Please attach involved professionals’ reports and Assess Plan Do Review (APDR) documents
These can be on a school template, or the LA template, but should clearly evidence that the graduated response has been exhausted and the impact of interventions and support	
Date identified as SEN Support level	What date did you identify as SEN Support i.e. put the child on the SEND register	
Attendance figure for the current academic year		

Provision Map – including frequency, hours, duration, size of group, etc. ( add rows as needed)	Impact	Date started	Date ended	
This is a crucial section to help the panel understand what provision the child has had and what they currently need. You need to include everything that you have done previously, and that you currently do, that is different from or additional to other children in your setting (see examples of strategies and support that may be included below). The first part of the table is for support you have decided to put in place as a setting, the second part is for support you have put in place following professional’s advice.
Please ensure you complete this section  i.e. do not put see support plan in this section as not all provision is included on support plans.	What has happened as a result of this intervention has the child achieved what you aimed for? Is the strategy still relevant and needed?	Date you first started the support/strategy	Date you finished the support/strategy. If it has not finished you can put ongoing.	
1:1 support meet and greet and sensory calming activity in quiet space upon arrival to setting
Daily x 15 minutes
	The sessions helped Bob to regulate his emotions and transition calmer into nursery during the first term. he now enters nursery with his peers.	06/09/23	21.12.23	
Adult to support child to play alongside others.
1:1 5 x 5 minutes per day
	With adult support Bob will now usually tolerate children close by for up to 5 minutes, if they do not interfere in his play.	08.10.23	Ongoing	
Adult support to manage child during meltdown/dysregulation 
1:1 daily as required	Bob and others around him are kept safe during meltdowns. With support Bob will calm after around 20 minutes.	06/09/23	Ongoing	
Adult monitoring of mouthing/putting toys in mouth and redirection
1:1 Full time support	 Bob will accept redirection to sensory chews and sensory activities using blowing and licking. he continues to require direct adult support for redirection.	06/09/23	Ongoing	
Adult support during outside play to ensure safety and prevent child absconding 
1:1 1 hour daily	With direct adult support and visuals Bob will now sometimes stop when the adult signs and says stops and leads him to another area.	06/09/23	Ongoing	
Adult support at lunchtimes to prevent child throwing food/taking others’ food
1:1 30 minutes daily	Bob will not tolerate sitting at a table with other children, and he cannot yet sit for lunch in the lunch hall. He sits in a small group quieter room, on a table 1:1. He will eat his lunch with this support but must be taken to another room as soon as he has finished eating else he will knock, grab and take other children’s food.	06/09/23	Ongoing	
What targeted support is in place for the identified needs – based on expert reports e.g. EP, SISS, SLT etc ….	Include here which professional’s/expert’s have recommended the support that is in place and impact e.g.:

EY Team:
simple Makaton signs in 1:1 intervention  
Daily x 15 minutes. Bob touches the adult hand in response to the Makaton sign for more, when motivated

Completion of adult directed tasks 
1:1 3 x 5 minutes daily 

Mirroring/intensive interaction 
1:1 4 x 5 minutes per day. Bob tolerates the adult near to him and notices when the adult mirrors his sounds and noises, often pausing and repeating the sound.

Anticipation games ready steady go  
1:1 2 x 10 minutes daily
Bob will make a sound (shout or scream) to communicate ‘Go’ when playing with bubbles. He will not yet engage in other activities using this strategy.

Friendly sabotage
1:1 5 x 5 minutes per day  
Bob will now initiate interactions with adults by leading them and pointing to objects that are out of reach, to communicate what he wants.

Object of reference or photo timetable use 
1:1 5 x 5 minutes per day  
Bob is responding to the Nappy object of reference, and now goes to be changed without crying/becoming dysregulated. He is not yet responding to other objects used.

SLT:

Mirroring/intensive interaction 
1:1 4 x 5 minutes per day. Bob tolerates the adult near to him and notices when the adult mirrors his sounds and noises, often pausing and repeating the sound.

Anticipation games ready steady go  
1:1 2 x 10 minutes daily
Bob will make a sound (shout or scream) to communicate ‘Go’ when playing with bubbles. He will not yet engage in other activities using this strategy.

Friendly sabotage
1:1 5 x 5 minutes per day  
Bob will now initiate interactions with adults by leading them and pointing to objects that are out of reach, to communicate what he wants.

SISS Autism Team:
Choice board with photos 
1:1 5 x 5 minutes per day  
Bob will eye gaze towards a picture to indicate his choice of snack and activity.

Sensory trail /circuits  
1:1 2 x 10 minutes daily

Physiotherapist:
Exercises to develop core strength and coordination
1:1 1 x 10 minutes daily

08.10.23

08.10.23

10.01.24

30.01.24	

Ongoing

Ongoing

Ongoing

Ongoing	

Pen Portrait 

Please give a brief description of how the child/YP functions in the educational setting in each of these four areas  ( box can be expanded as needed) 	
Communication and Interaction 	Cognition and Learning	Social, Emotional and Mental Health	Physical and Sensory	
Strengths:

In the strengths section detail what the child can do/how they function in setting in each of the four areas listed at the top of the columns – if the child can only do something with adult support make this clear. Try not to make vague/general comments, be specific i.e. if a child will only play next to others but not with others, put this not, ‘he plays with friends’. 
Examples:
Bob will tap the adult’s hand to communicate ‘more’ during 1:1 sessions with bubbles.
Bob will scream, shout to communicate ‘Go’ during Ready Steady Go games.
Bob has started to lead an adult, then point to a toy that is out of reach.
Bob loves songs, and will often sing these.
Bob can say shape names, numbers 1-10, colours and the letters of the alphabet.
Bob will occasionally follow the simple, routine instruction ‘Nappy’ with a visual objects of reference,  and 1:1 adult support to lead him by the hand but this is limited and not yet consistent. 

	Strengths:

Bob will focus for longer periods (up to 5 minutes) on his main interests independently, which are pushing a vehicle back and forth whilst watching the wheels and water play. 
Bob joins a small group ‘Attention Bucket’ session with a high level of adult support (1:2).
Bob sits on the carpet for group time when supported by an adult, but is not yet accessing group learning.
Bob can say shape names, numbers 1-10, colours and the letters of the alphabet.
Bob can complete simple inset jigsaw puzzles.
	Strengths:

Bob engages in intensive interaction sessions for a brief period (1-2 minutes) he will notice when adults copy his sounds and will smile and make more sounds.
With adult support, Bob has begun to tolerate children playing next to him, for up to 5 minutes.
Bob recognises his mum when she collects him from nursery; he will smile and laugh when she arrives. 
	Strengths:

Bob loves to climb; he can climb up and down on the climbing apparatus independently.
Bob can jump up and down on the trampolines
Bob walks and runs with control; he can run quickly whilst negotiating furniture and obstacles.
Bob enjoys playing on the bikes with stabilisers, which he can pedal independently.
Bob shows good hand/eye coordination.
Bob makes circular marks using paint and crayons.
	
Challenges:

In the challenges section clearly detail what the child has difficulties with when describing how they function in setting in the area. Examples:
Bob’s delays in language and communication development cause him to become extremely frustrated and dysregulated many times throughout the day.
Bob mainly communicates his needs through behaviour, he will scream, throw himself to the floor and repeatedly bang his forehead on furniture, or the floor, if he doesn’t like something, want something, or is frustrated. 
Bob does not initiate any interaction with the other children unless they touch/interfere in his play.

.

	Challenges:

Bob spends long periods of time pacing or circling the setting. 
Bob’s attention is brief and fleeting; he tends to flit between toys and activities focussing for up to 30 seconds on objects of interest.
Bob becomes dysregulated and has an emotional meltdown if we attempt to get him to join group carpet/learning times. 
He usually refuses to follow any adult led/directed task and will scream, and throw himself to the floor. 
He is currently accessing a bespoke and highly adapted EYFS curriculum.

	Challenges:

Bob quickly and frequently becomes dysregulated, and he will scream, kick, throw himself to the floor and repeatedly bang his forehead on furniture, or the floor, if he doesn’t like something, want something, frustrated or stopped from doing something that he wants.
Bob regularly appears in ‘his own bubble’ where he will look up into the air, babble, smile and laugh to himself.
Bob is always solitary in nursery and shows no interest in other children. 
He has no understanding of sharing or turn taking and will grab/take toys from/lash out at others. 
He cannot adapt his play to others. 
Bob does not follow any of the nursery’s routines, staff must provide him with 1:1 support and a routine adapted to his needs.
Bob persistently lacks the ability to risk assess his own safety; he climbs up furniture and onto windows and he will run off through any open door/gate. He does not understand where he should and shouldn’t go.
At snack and lunch times, Bob will grab/take food from other children’s lunches and hands. 
	Challenges:

Bob frequently seeks sensory experiences such as water and sand, putting non-food items in his mouth. Bob frequently mouths/licks/puts toys and small objects into his mouth. 
Bob frequently sensory seeks through biting toys/objects/people around him. He requires a high level of support to redirect him to sensory alternatives.

He repeatedly throws objects and toys in nursery. 
Bob frequently rocks vigorously back and forth, both when seated and standing.
Bob is restrictive in his eating; he will often eat very little at lunch times and needs an adult to encourage him to eat; staff often must provide opportunities to ‘graze’ throughout the afternoon to ensure that Bob has eaten.

Part 5: HEALTH INFORMATION – provided by parent/young adult 

Does your child or young person have any existing diagnoses or health needs? Please list them here with the name of the professional who gave the diagnosis. 	
January 2024 – Diagnosis of Autism – Specialist Assessment Service -  Dr A. Smith

Please send any medical reports you would like to be taken into account. N.B we are unable to see any reports that might be on the NHS system 	

	Y/N	Details 	
Does your child have any health needs that are routinely addressed in school? E.g tracheostomy, epilepsy, PEG feeding etc. (this does not refer to regular medications e.g. ADHD meds, antibiotics etc)	N		
If your child is under 18, would you like your child to be seen by a paediatrician?
	Y – if the child is not already under a paediatrician would parents like them to be seen by one?	Please note: if you select ‘no’ to the above we will only seek advice from the health care professionals who you have told us are currently working with your child.

Part 6: SOCIAL CARE INFORMATION – provided by parent/young adult

By completing the following questions  social care can look at how we may be able to offer assistance through services such as our local offer, or other support which may be offered if you meet service eligibility criteria. 

This information will be used to ascertain whether you require an assessment of need from Social Care as part of an EHC Needs Assessment. 

The questions below should be read in context of your (if young adult) / your child’s age and for very young children; consider if there is anything you are required to do that is over and above what could be reasonably expected of a parent with a child of the same age.

A description is required for each question but if helpful you can bullet point your answers.

Area	No	Yes	Please provide information where appropriate	Impact on everyday life 	
Have you had a parent/carer assessment through the Carers’ Trust?

If no would you like one?				n/a	
Has your child/YP accessed short break activities through solo/local offer? 

If no would you like more information about this?				n/a	
Does this child/young adult have a disability or other difficulty?

			Detail if the child receives DLA		
Does this child/young adult have behaviours that challenge, including any specific emotional or behavioural difficulties?					
Does this child/young adult need lots of help with personal care, e.g. bathing, dressing, toileting, which you may need help with?					
Does this child/young adult need help accessing activities or joining in friendships in a safe and meaningful way?					
Is family time together shared equally with other members of the immediate family?
					
Is there anything the parent/carer feels they need that would support in managing their child’s needs?					
Does this child/young adult & their family have a support network, e.g. family/friends/other forms of support?					

Part 7: SUBMISSION CHECKLIST

REMEMBER TO INCLUDE WITH THIS REQUEST:

Completed the attainment and progress information				
Complete the information about current provision				
Attach a current Provision map 				
Attach APDR cycles – clearly showing impact of interventions				
One or two samples of recent work, dated & annotated accordingly ( may not be appropriate for EYFS)				
Relevant reports from involved professionals, e.g. Health/Social Care, SISS, EP etc				
Any other relevant information to support the request				

Requestor’s signature		Requestor’s name		
Senior manager’s signature		Senior manager’s name		
Position		Date request submitted		

Please submit this form with the supporting evidence via email to
edsen@solihull.gov.uk 

If you have any queries relating to the submission of this form, including how to submit it if you do not have access to email,  please contact the EHCP Service on 0121 704 6690