Please describe the nature of support you feel you require ...€¦ · Web viewPlease describe...
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Early Years Request for Seedlings Placement Child’s full name Preferred name Referrer details Person making this Request Name Positi on / Role Referrer address including postcode Contact telephone number Email address Checklist for Request Request form – all sections must be
Transcript of Please describe the nature of support you feel you require ...€¦ · Web viewPlease describe...
Early Years Request for
Seedlings Placement
Child’s full namePreferred name
Referrer detailsPerson making this Request
Name Position / Role
Referrer address including postcode
Contact telephone numberEmail address
Checklist for RequestRequest form – all sections must be completedand include a ‘hand written’ signature by Parent(s) / Guardian(s) and Referrer
Yes / No
Parental/Guardian Consent form must be completedYes / No
Child’s details
Child’s name Date of Birth GenderReligionEthnicity(tick box)
WBRI (White British)
WRI (White, Irish)WIrt (Traveller of Irish Heritage)WROM (Gypsy / Roma)WOTH (White, any other White background)MWBC (Mixed, White and Black Caribbean)MWBA (Mixed, White and Black African)MWAS (Mixed White and Asian)MOTH (Mixed, any other mixed background)AIND (Asian or Asian British, Indian)APKN (Asian or Asian British, Pakistan)ABAN (Asian or Asian British, Bangladeshi)AOTH (Asian or Asian British, any other Asian background)BCRB (Black or Black British Caribbean)BAFR (Black or Black Brisith African)BOTH (Black or Black British, any other Black Background)CHNE (Chinese)OOTH (Any other ethnic background)REFU (Did not wish to be recorded)NOBT (Not obtained)
Parent / Guardian Name (s) andhome address
(Indicate parental responsibility) Parental responsibility Yes / No
Contact numbers Landline MobileHome LanguageSocial Care Status‘Child looked after’ ?(CLA) (if applicable)If Yes, social worker’s name and contact details
Yes / No
Primary SEN Need (DfE Code)
SpLD / SLCN / ASD / PD / SEMH / PMLD / MLD / SLD / HI / VI / MSI
Other (SEN) Need SpLD / SLCN / ASD / PD / SEMH / PMLD / MLD / SLD / HI / VI / MSI
Has an Early Help Assessment been completed?
Yes / No Date commenced
If ‘Yes’ please indicate level (tick box) UniversalUniversal PlusPartnership responseSafeguarding
If ‘Yes’ please indicateName of Lead ProfessionalPositionContact telephone numberEmail address
Has an Ages and Stages Questionnaire (ASQ) been completed? Yes / NoIf ‘Yes’ please indicate at what age 24 months / 36 months
Education Provider detailsProvider addressincluding postcode
Contact telephone numberEmail addressNumber of hours of Free Nursery Entitlement or Number of hours Early Years Provision FundingName of SENDCoName of child’s Key PersonDate started in the provisionIs the provision in receipt of Disability Access Fund? Yes / NoNumber of hours the child is attending the provisionFuture provision / school the child will attend
Name Start Date
Further detailsName Service Date of
involvement from - to
Assess-Plan – Do – Review Cycle
Other people/ services currently involved with the child
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Other people/ services previously involved with the child
Attendance informationMonday Tuesday Wednesday Thursday Friday
Start Time
End time
Total number of hoursStaffing ratio
Referral InformationPlease describe the nature of support you feel you require to support the child.
Observations:Please attach a minimum of 2 detailed observations specific to your area of concern (observations could include narrative, tracking, event sample etc.)
These observations should be taken at different times and in different contexts.
Please ensure you state: Date, time, duration, context/situation, details of the activity and aims, adult involvement and child group.
Date of observation 1:
Date of observation 2:
Evaluation of observations:(Please evaluate all observations submitted)
Following the evaluation of your observations, please provide supporting information:
What recommendations have been made?
How these have been implemented and over what period of time?
What learning outcomes is the child working towards? Progress made towards the outcomes?
How planning has been differentiated?
Ensure you detail what strategies/resources are being deployed and by whom?
Initial concerns raised by: (please name and state capacity e.g. parent, staff member, other agency)
What is working: the impact of effective strategies and interventions on education and wider outcomes.
What is not working: reasons why strategies and interventions have been discontinued?
How strategies and interventions are evaluated:
Child’s progress in Early Learning GoalsPlease summarise progress when last assessed
Primary Area Aspect Date assessed
Child’s ageYear : Month
Development level
Personal, Social & Emotional
Making relationshipsSelf-confidence & self-awarenessManaging feelings & behaviour
Communication & Language
Listening & attentionUnderstanding
Speaking
Physical Development
Moving & handlingHealth & self-care
Specific Areas Literacy
Mathematics
Understanding the worldExpressive arts & design
Permission to initiate Person Centred SEN Support Plan Yes / NoPermission to share the Person Centred SEN Support Plan documentation Yes / No
Authorisation
ReferrerAuthorisation for the RequestProvision Manager
Name Position
Signature
Date
Parent/GuardianAgreement ofParents(s) /Guardian(s)
Name
Signature
Date
Date submitted to the Local Authority
Please email to: [email protected] return to:Early Years Inclusion TeamFloor 3The Civic BuildingWaterdaleDoncasterDN1 3BU
Early Years Inclusion Team - Partnerships and Operational Delivery
Doncaster Metropolitan Borough CouncilThe Civic Building, Floor 3, Civic Quarter, Waterdale, Doncaster, DN1 3BU
