INFORMATION FORM for 1st MEETINGS

Please make sure that you return this form to us by email to

team@dsslaw.co.uk

at least 24 hours before our 1st meeting

(please leave yourself enough time to complete it)

PLANNED DATE OF MEETING
DATE FORM COMPLETED/BY WHOM
WHERE DID YOU HEAR ABOUT US?

ABOUT YOU

TITLE, FIRST NAME & SURNAME
YOUR DOB
YOUR OCCUPATION (optional)
YOUR SPOUSE/PARTNER’S NAME
THEIR DOB
THEIR OCCUPATION (optional)
NAME OF OTHER PARENT OF CHILD (if relevant)
YOUR RELATIONSHIP WITH OTHER PARENT	e.g. Married/Partner/Separated/Divorced/Other - (please also state when if applicable)

YOUR CONTACT DETAILS

ADDRESS
HOME TEL. NO.
WORK TEL. NO. (YOU)
WORK TEL. NO. (OTHER PARTNER)
MOBILE TEL. NO (YOU)
MOBILE TEL. NO. (OTHER PARENT)
YOUR EMAIL (1)
YOUR EMAIL (2)
OTHER PARENT EMAIL (1)
OTHER PARENT EMAIL (2)
NAME OF LOCAL AUTHORITY

ABOUT YOUR CHILD (i.e. who you are coming to see us about)

FULL NAME
DATE OF BIRTH
M/F
NAME & ADDRESS OF CURRENT SCHOOL
TYPE OF SCHOOL (e.g. maintained/ non-maintained / independent, mainstream/mainstream with unit/special school, other [please give details])
CURRENT SCHOOL YEAR

ABOUT THE REST OF YOUR FAMILY

(You only need to indicate where the child above fits into the family)

CHILD 1

FULL NAME
DOB
M/F
FULL/HALF SIBLING
CURRENT SCHOOL
TYPE OF SCHOOL
CURRENT SCHOOL YEAR
ANY SEN/DISABILITY? (if so, what?)

ABOUT THE REST OF YOUR FAMILY (cont …)

CHILD 2

FULL NAME
DOB
M/F
FULL/HALF SIBLING
CURRENT SCHOOL
TYPE OF SCHOOL
CURRENT SCHOOL YEAR
ANY SEN/DISABILITY? (if so, what?)

CHILD 3

FULL NAME
DOB
M/F
FULL/HALF SIBLING
CURRENT SCHOOL
TYPE OF SCHOOL
CURRENT SCHOOL YEAR
ANY SEN/DISABILITY? (if so, what?)

ABOUT THE REST OF YOUR FAMILY (cont…)

CHILD 4

FULL NAME
DOB
M/F
FULL/HALF SIBLING
CURRENT SCHOOL
TYPE OF SCHOOL
CURRENT SCHOOL YEAR
ANY SEN/DISABILITY? (if so, what?)

CHILD 5

FULL NAME
DOB
M/F
FULL/HALF SIBLING
CURRENT SCHOOL
TYPE OF SCHOOL
CURRENT SCHOOL YEAR
ANY SEN/DISABILITY? (if so, what?)

ABOUT YOUR CHILD’S SEN/DISABILITY

(Please tick all of your child’s SEN/Disabilities below where relevant – you can also find out more information about these conditions if you click on the link and hold CTRL on your computer. Please indicate BOTH whether you feel your child has this SEN/Disability AND whether there has been a formal diagnosis.

YOUR VIEW	DIAGNOSIS	YOUR VIEW	DIAGNOSIS
ADHD	Down's Syndrome
Agenesis of the Corpus Callosum (ACC)	Duane Syndrome
Angelman Syndrome	Dysarthria
Aniridia	Dyscalculia
Anxiety Disorders	Dysgraphia
Aphasia	Dyslexia
Apraxia	Dysnomia
Arthritis	Dysplasia
Asperger's Syndrome	Dyspraxia
Asthma	Echolalia
Attachment Disorder	Ehlers-Danlos Syndrome
Atypical Autism	Emotional & Behavioural Difficulties (EBD)
Auditory Processing Disorder	Emotional Literacy
Autism (ASD)	Epilepsy
Brain Injury	Fragile X Syndrome
Cerebellar Ataxia	Global Developmental Delay
Cerebral Palsy (CP)	Glue Ear
Challenging Behaviour	Graphomotor Skills
Conduct Disorder	Guillain Barré
Crohns Disease	Hearing impairment (HI)
Cystic Fibrosis (CF)	Heller's Syndrome
Developmental Delay	Hydrocephalus
Diabetes	Hyperacusis

YOUR VIEW	DIAGNOSIS	YOUR VIEW	DIAGNOSIS
Hyperlexia	Proprioception
Hypermobility	Rett Syndrome
Hypotonia	Scoliosis
Irlen Syndrome/Scotopic Sensitivity	Selective Mutism
Landau Kleffner Syndrome	Semantic Pragmatic Disorder
Learning Disabilities	Sensory Integration Disorder (SID)
Moderate Learning Difficulties (MLD)	Severe Learning Difficulties (SLD)
Mood Disorder	Sickle Cell Anaemia
Mowat-Wilson Syndrome	Social Skills
Multi-Sensory Impairment (MSI)	Sotos Syndrome
Muscular Dystrophy	Speech & Language Disorder
Neurofibromatosis	Spina Bifida
Non-Verbal Learning Difficulties (NLD)	Tactile Defensiveness
Noonan Syndrome	Tourettes Syndrome
Obsessive Compulsive Disorder (OCD)	Turner Syndrome
Oppositional Defiant Disorder (ODD)	Ulcerative Colitis
Osteogenesis Imperfecta (OI) (Brittle Bone Disease)	Usher Syndrome
Pathological Demand Avoidance	Visual Impairment
Pervasive Developmental Disorder	Waardenburg Syndrome
Peter's Anomaly	Williams Syndrome
Physical Disability (PD)	Working Memory
PMLD	Worster-Drought Syndrome
Prader-Willi Syndrome	Other (please state)
Other:

HOW DID YOUR CHILD DEVELOP HIS/HER SEN/DISABILITY AND AT WHAT AGE? (e.g. birth injury/accident, genetic, unknown ETC.)

ABOUT YOUR CHILD’S EARLY YEARS SETTINGS/SCHOOLING

MONTH/YEAR	NAMES OF EARLY YEARS SETTING/S:	TYPE OF PLACEMENT	EARLY YEARS ACTION/ ACTION+/SEN SUPPORT STATEMENT/EHCP
1 –
2 –
3 –

MONTH/YEAR	NAMES OF PRIMARY SCHOOL/S:	TYPE OF PLACEMENT	SCHOOL ACTION/ ACTION+/SEN SUPPORT STATEMENT/EHCP
Reception:
Year 1:
Year 2:
Year 3:
Year 4:
Year 5:
Year 6:

MONTH/YEAR	NAMES OF SECONDARY SCHOOLS:	TYPE OF PLACEMENT	SCHOOL ACTION/ ACTION+/SEN SUPPORT STATEMENT/EHCP
Year 7:
Year 8:
Year 9:
Year 10:
Year 11:

MONTH/YEAR	NAMES OF POST – 16 SETTINGS:	TYPE OF PLACEMENT	SCHOOL ACTION/ ACTION+/SEN SUPPORT STATEMENT/EHCP
Year 12:
Year 13:

ABOUT ANY ASSESSMENTS/REASSESSMENTS

DATE REQUEST MADE	DATE OF AGREEMENT	DATE OF REFUSAL
1 -
2 -
3 -
4 -
5 -

ABOUT ANY PROPOSED/FINAL STATEMENTS/EHC PLANS

DATE OF STATEMENT/EHCP	TYPE (i.e. Proposed/Amended/Final)
1 -	Proposed/Amended/Final
2 -	Proposed/Amended/Final
3 -	Proposed/Amended/Final
4 -	Proposed/Amended/Final
5 -	Proposed/Amended/Final

ABOUT ANY ANNUAL REVIEWS

DATES OF ANNUAL REVIEWS:
1 –	Copy to be provided? YES/NO
2 –	Copy to be provided? YES/NO
3 –	Copy to be provided? YES/NO
4 –	Copy to be provided? YES/NO
5 –	Copy to be provided? YES/NO
6 –	Copy to be provided? YES/NO
7 –	Copy to be provided? YES/NO
8 –	Copy to be provided? YES/NO
9 –	Copy to be provided? YES/NO
10 –	Copy to be provided? YES/NO

IF YOU ARE APPEALING TO THE SEND TRIBUNAL

WHAT IS THE DATE OF THE LOCAL AUTHORITY’S DECISION LETTER?
WHAT DATE DID YOU RECEIVE IT?

WHAT IS IT YOU WANT?

DO YOU HAVE ANY SPECIFIC QUESTIONS FOR US?

1 –
2 –
3 –
4 –
5 –

THANK YOU FOR YOUR TIME IN COMPLETING THIS FORM. IT WILL HELP US HELP YOU.