This is Me - How were my views included in my education health care plan?

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1. How did the child/young person complete this survey?

Independently
With support
Parent / carer completed following observations of child
School staff completed following observations of child
Other (please specify):

2.
Child / Young Persons full name

3. Child/young person's date of birth

4. Are you completing this survey as a response to your first EHCP (newly issued) or as part of an annual review process (existing)?

Newly Issued Plan
Existing Plan

5. Date Completed:

6. Full name of adult supporting, your relationship to child/young person and the method you used to gather the child/young person's views e.g. observation, talk, picture

7. I was given the chance to give my views by completing the "This Is Me" form or similar (e.g. a discussion with SENDCO, was observed in my environment to see what I needed, etc.)

Yes
No
Don't Know
Other (please specify):

8. I was given the chance to give my views by completing the this is me form or similar (for example discussion with SENDCO, was observed in my environment to see what I needed)

Yes
No
Don't Know
Other (please specify):

9. I get the support I need in School/College

Yes
No
Don't Know
Other (please specify):

10. I have the support I need from Health Services

Yes
No
Don't Know
Other (please specify):

11. I felt listened to during the EHCP process

Yes
No
Don't Know
Other (please specify):

12. I am Safe

Yes
No
Don't Know
Other (please specify):

13. I am Happy

Yes
No
Don't Know
Other (please specify):

14. I have aspirations for my future

Yes
No
Don't Know
Other (please specify):

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