Is someone helping you complete this form?*

Yes

No

Please tell us the contact details of the person helping you

Name*

Role*

Email address*

Telephone number*

Do you consider yourself to have a disability, learning disability or mental health difficulty?*

Yes

No

Please give details of any additional needs and confirm if you are receiving any support for the needs you have told us about*

Do you need support with understanding written and spoken English?*

Yes

No

Please give details on how we can help you with understanding written and spoken English*

Your name*

Your relationship to the child/young person*

Your telephone number*

Your email address*

Address line 1*

Address line 2

Town/city

County

Postcode*

Is the child/young person aged 16 or over?*

Yes

No

Has the child/young person given their consent for: *

the use and storage of their personal data by Essex SEND IASS to enable them to provide information advice and support
for Essex SEND IASS to access the local authority education database to respond to the enquiry

*

Yes

No

You will need to obtain consent from the child/young person before you can make a referral.

I consent to the use and storage of my own and the child/young person’s personal data by Essex SEND IASS to enable them to provide information advice and support regarding my enquiries*

Yes

No

I consent for Essex SEND IASS to access the Local Authority education database to respond to my query.*

Yes

No

Child/young person’s name*

If you are happy to, please tell us the child/young person’s ethnicity

Age*

Year group*

Date of birth*

Special educational need / diagnosis*

Name of education setting*

Does the child/young person have an SEN Support plan/One Planning?*

Yes

No

Don’t know

Does the child/young person have an Education, Health & Care plan?*

Yes

No

Don’t know

Are there any services/agencies currently involved?

Agency/agencies involved*

Are there any local authority professionals involved?*

Yes

No

E.g. Inclusion Partner, Educational Psychologist, Engagement Facilitator, Attendance Specialist or Education Access. If yes, please provide brief details of who is involved.

Which professional(s) are involved?*

If you would like us to make enquiries on your behalf with local authority services or other professionals, do you give us permission to share your child’s information?*

Yes

No

In as much detail as possible, please explain how we can help you*

For example:
• Who is involved at school or local authority?
• What is working not working?
• Have you raised concerns and who with?
• How would you like us to help you?

Please enter how you heard about us*

Parent/Carer

Your details

Child/young person’s details

Child/young person’s diagnosis / SEN needs