For support in completing this document please refer to the How to request an EHC needs assessment? document. Note: Please ensure you have read the and the prior to completing and submitting this form. Part 1: Pupil, Parent/Carer and School details Name of child / young person: UPN: Date of birth: Year group: Date of request: Home language: School admission date: Gender: NHS number: Attendance (last % 12 months): Is this child/young person looked after (please tick)? Yes Authority (if yes): No School name: School address: Named school contact: Designation: Telephone number: Email: Parent/ carer / guardian 1) 2) (if different from 1) Names: Does this person have parental responsibility (PR)? (Please tick): If those detailed above do not have PR, who does? Please provide details: Is either parent in the armed forces? Does this child/young person If yes, please provide contact details: currently have involvement from a Social Worker? If no, has a scanned copy of an Early Help referral form Yes been attached? (please tick):
For support in completing this document please refer to the How to request an EHC needs assessment? document. Note: Please ensure you have read the and the prior to completing and submitting this form. Part 1: Pupil, Parent/Carer and School details Name of child / young person: UPN: Date of birth: Year group: Date of request: Home language: School admission date: Gender: NHS number: Attendance (last 12 months): % Is this child/young person looked after (please tick)? Yes No Authority (if yes): School name: School address: Named school contact: Designation: Telephone number: Email: Parent/ carer / guardian Names: 1) 2) (if different from 1) Does this person have parental responsibility (PR)? (Please tick): If those detailed above do not have PR, who does? Please provide details: Is either parent in the armed forces? Does this child/young person currently have involvement from a Social Worker? If yes, please provide contact details: If no, has a scanned copy of an Early Help referral form been attached? (please tick): Yes
ehcp-school-request-form.docx