l. Do you / this person have a Yes Yes Yes Yes Yes No No No No No disability or an additional Don’t Know Don’t Know Don’t know Don’t Know Don’t know need? Briefly explain the impact on you / this person of having a disability or additional need: SEN support SEN support SEN support SEN support SEN support m. Do you / this person have a Special Educational Need? If so, what level of support do Higher needs Higher needs Higher Higher needs Higher needs they receive? (please tick Funded (what Funded (what Funded (what Funded (what Funded (what relevant box) type) type) type) type) type) Statement or Statement or Statement or Statement or Statement or Education, Health and Care EHC Plan EHC Plan EHC Plan EHC Plan EHC Plan (EHC) Plan 5. Adults in your home and adults who do not live with you but are important to them Adult 1 Adult 2 Adult 3 Adult 4 Adult 5 a. First name b. Surname c. Also known as d. Date of birth (DD/MM/YYYY) if known e. Gender Adult 1 Adult 2 Adult 3 Adult 4 Adult 5 f. Relationship to you / each
l. Do you / this person have a disability or an additional need? Yes Yes Yes Yes Yes No No No No No Don’t Know Don’t Know Don’t know Don’t Know Don’t know Briefly explain the impact on you / this person of having a disability or additional need: m. Do you / this person have a Special Educational Need? If so, what level of support do they receive? (please tick relevant box) Education, Health and Care (EHC) Plan SEN support SEN support SEN support SEN support SEN support Higher needs Funded (what type) Higher needs Funded (what type) Higher Funded (what type) Higher needs Funded (what type) Higher needs Funded (what type) Statement or EHC Plan Statement or EHC Plan Statement or EHC Plan Statement or EHC Plan Statement or EHC Plan 5. Adults in your home and adults who do not live with you but are important to them Adult 1 Adult 2 Adult 3 Adult 4 Adult 5 a. First name b. Surname c. Also known as d. Date of birth (DD/MM/YYYY) if known e. Gender Adult 1 Adult 2 Adult 3 Adult 4 Adult 5 f. Relationship to you / each