Confidential Request Form

Updated: 03/02/20
Confidential Request

This form is to request school-commissioned work - please complete as fully as possible

Confidential Request for
If this is a request for a particular team involvement, tick one box:

Child / Young Person Details

Year Group (B) (Please select Reception or Pre-school)
Mainly taught out of year group *
Statement of SEN / EHCP *
Is attendance an issue? *

Family Details

Is a translator needed for parent/child/young person
If yes, school to arrange

Educational Setting Details

Previous Educational Setting(s)

- If child admitted during the past year, with admission dates

School Information about the Child / Young Person

Is the child / young person already known to this service?

Current Levels of attainment:

Please give child's / young person's current levels of attainment in:

In-school support currently in place:

Attach additional Intervention summaries documents here.
Drop a file here or click to upload Choose File
Maximum upload size: 8.39MB

Support from other Professionals

Does the child / young person attend an SRB, or receive 'outreach' support from an SRB, Short Stay School for Norfolk or the School2School Support Service?
Has the Family Support Process been started?
Please indicate other professionals / agencies who are currently / have been involved with the child / young person *
Has there been a medical diagnosis? *

Parent / Carer Consent

It is important that parents / Carers understand the reasons for making the request. We can only work with the child / young person with parent / carer understanding and consent.

The Educational Psychologist / Specialist Learning Support Teacher / Clinical Psychologist may:

  • Talk to your child's teacher and other people who know your child well
  • Observe your child in class
  • Work with your child to complete some individual assessments
  • Review Children's Services records for your child

I agree to this request for support by the Educational Psychology and Specialist Support Service. The contents of this form have been discussed with me.

I understand that i will be notified of the date of the appointmnt, I will have the opportunity to meet the professional and that i will receive written feedback about the outcomes of the consultation / assessment / intervention.

I understand that information from the consultation / assessment may also be shared or discussed with other professional services if that is in the best interests of my child, and will be stored securely for future reference.

Where child has sufficient understanding:

I have discussed the reason for making this request with my child

School Authorisation

We have discussed the reasons for making this request with the child / young person
Signature of Professional who obtained parental and / or young person's agreement and Head Teacher's Signature

Please return to Children's Services, EPSS at the email address on Page 1 and copy to the Educational Psychologist and / or Specialist Learning Support Teacher if known.

Note: To avoid delays in our response, please ensure that forms are fully completed.

Keep a signed copy for your records