Compass 0-17 Year Form

Compass Brighton & Hove Registration Form 0 to 17 years

for children and young people aged 0-17
The Compass B&H disability register is for children or young people aged up to 25 years whose special educational need and or disability (SEND) has a big effect on their daily life. They must live or access education in Brighton & Hove or be a 'looked after' child by Brighton & Hove social services.

This form is for 0 to 17 years. If the young person is aged over 17 years, please email compass@amazesussex.org.uk and we will post you a form; sorry the 18-25 years form is not available online yet.

If you cannot complete the form in one session, click the 'Save and Continue Later' button. You do not need to create a JotForm account, select 'Skip Create an Account' and add your email address to be sent a link.

Please read our privacy statement here, by completing this form you will will be agreeing to Amaze processing the data you give us in this form. If you are a parent carer completing the form for a 16 or 17 year old, please make sure the young person has consented for you to share their data here.
Are you a young person aged 17 or less completing this form for yourself?*
Thank you, just to let you know, when this form says the 'child or young person' we mean you.
Where does the child or young person live?
Where does the child or young person go to nursery, school or college?
Is the child or young person 'looked after' by Brighton & Hove social services?
Is the child or young person temporarily housed by Brighton & Hove council?
We are very sorry but the Compass card is only available for children or young people with SEND who meet one of the following criteria:
- Live in Brighton & Hove
- Attend nursery, school or college in Brighton & Hove
- Are 'looked after' by Brighton & Hove Social Services
- Are temporarily housed by Brighton & Hove City Council
Please confirm that you have checked your child or young person meets the eligibility criteria above and that you are happy for Amaze to process all the data in this form.*

I am happy for Amaze to process our data

About the person completing this form
Your Email (the person completing the form)*
example@example.com
Please check your email address is correct:

{yourEmail}
Yes my email address is correct, please tick*
Your Mobile Number (the person completing the form)
E.g. 07000 123123
Please enter a valid mobile number
Your Landline (the person completing the form)

Area CodePhone Number

The child or young person's details
The child or young person's name*

First NameLast Name
The child or young person's address*

Address Line 1

Address Line 2

Town/CityCounty

Postcode
The child or young person's date of birth*

DayMonthYear
{theChild22} is aged {age} years.
As you are under 16 years and completing this form yourself, we will still need your parent carer to complete some of the form.
As you are completing this form for a 16 or 17 year old, please confirm that they are happy for Amaze to process the data you provide in this form.*

My young person consents to me sharing their data in this formI am consenting for my young person, as they do not have capacity to do so
This form is for 0 to 17 years. Please email compass@amazesussex.org.uk if you require the 18 up to 25 years form.

Child or Young Person's Diversity Information
What is the child or young person's gender identity?*
What was their sex at birth?*
Is English the main language spoken at home?*
What is the main language spoken at home?*
Language
What is the child or young person’s ethnic origin?*
What is the child or young person’s religion or beliefs?*

School and GP Surgery
Which of these education options apply to the child or young person?*
What is the name of the nursery, school or college?*
Please select the GP Surgery where the child or young person is registered*
Sorry the GP surgery is not listed, please type in the surgery name here
We know many children have more than one need or condition. In the following question we ask you about their most significant (primary) need or disability. On the next page you can select all their conditions as well as specify any genetic or named syndromes or other conditions not listed.
Which of your child or young person's needs/conditions would you see as their most significant (primary) need or disability?*

Tell us more about the child or young person’s needs
Does the child or young person have a learning difficulty or learning disability?*
Does the child or young person have any difficulties with communication?*
Does the child or young person have visual problems?*
Does the child or young person have hearing problems?*
Does the child or young person receive Disability Living Allowance (DLA) or Personal Independence Payment (PIP)?*
Please tell us more about this so we can understand better why you’re not in receipt of DLA/PIP? *
Is your child or young person entitled to free school meals?

Does the child or young person have behaviour that is a concern?*
Does the child or young person have mobility problems?*
What personal care (e.g. washing, dressing, feeding) does the child or young person need?*
Does the child or young person have any issues with eating (e.g. physical eating problems or sensory difficulties)?

Are the child or young person’s toileting skills what you would expect for their age?
Does the child or young person need to use a hoist-assisted toilet or changing facilities?
Does the child or young person need constant supervision?*
How does the child or young person usually sleep?*
Does the child or young person travel by public transport?

Child or young person's diagnosis, needs and care
Does the child or young person have a condition that requires medical treatment or intervention every day? (e.g. taking medicines, physiotherapy, asthma pump) *
How many health-related appointments has the child or young person had in the last 12 months? (including annual health checks for young people aged 14 and over with a learning disability)*
How many days has the child or young person spent in hospital in the last 12 months?*
If the child or young person has a GP, do they have a good grasp of the child or young person’s needs?
Does your child or young person get dental care?

Child or young person's education
Is the child or young person struggling to attend nursery/school/college regularly?
What support does the child or young person have at nursery, school or college?*
Has the child or young person been officially suspended or excluded from school in the past 12 months?
Has the child or young person been informally suspended or excluded from school in the past 12 months?
Please tick all reasons why they have been informally suspended or excluded

Sent home earlyParent carer asked to collect during school hoursExcluded from certain activitiesPart-time timetable, without clear plan for reintegrationInternal exclusion for longer than is necessary
Has the child or young person ever experienced bullying at nursery/school/college?
Has the child or young person ever experienced bullying out of nursery/school/college?

About the parent carer completing the form
The remainder of this form should be completed by your parent carer.
What is your relationship to the child or young person?*
Your Name*

First NameLast Name
What is your gender identity?*
Do you live at the same address as the child or young person*
Your Address*

Address 1

Address 2

Town/CitySussex

Postcode
Is the child or young person a ‘looked after’ child? (A 'looked after' child is under the care of the local authority)*
Please provide the name and contact details of the social worker so we can contact them for consent to register the child or young person.
Social worker name*

First NameLast Name
Social worker phone number*
Social worker email*
example@example.com
Having an Education, Health and Care (EHC) Plan or getting Disability Living Allowance (DLA) or Personal Independence Payment (PIP), is how we usually check if someone is eligible for Compass. As your child or young person does not currently have these in place, it would helpful if you can tell us how their additional needs effect their daily life.

0/150

	Received	Needed
Audiology
Bladder and bowel service (toileting and continence support)
Community paediatric nurse
Complementary therapies
Dietician
Health visitor
Health visitor (specialist)
Hydrotherapy
Occupational therapy
Paediatrician (community i.e. Seaside View child development centre)
Paediatrician (hospital)
Physiotherapy
Psychological therapy (e.g. play or music therapy, CBT, psychotherapy)
School nurse
Sleep clinic
Specialist CAMHS (Children and Adolescent Mental Health Service)
Specialist dentist
Speech and language therapy
Wellbeing service for children and young people aged 4-25
Wheelchair and seating service

	Received	Needed
Advice services (e.g. benefits or careers advice)
Amaze - information and advice services
Amaze - peer support for parent carers
Amaze - Amazing Futures
Amaze - Amazing Careers
AmazeXtra
Blue badge
Chestnut Tree House
Childcare (pre-school, breakfast, after school clubs, holiday scheme)
Crossroads Care
Food bank
Local parent group/support
National charity/support group
Play, leisure and sporting activities

	Received	Needed
Autism support (BHISS)
Early years support (BHISS)
Educational psychologist (BHISS)
Language support (BHISS)
Literacy support (BHISS)
Schools wellbeing service (mental wellbeing in schools)
Sensory needs support (hearing or visual Impairment - BHISS)
Social, emotional and mental health support (BHISS)
EMAS (Ethnic Minority Achievement Service)
EOTAS (Education Other Than at School)
Home to school transport
Home to school transport with escort
Independent travel training
Youth Employment Services

	Received	Needed
Adaptations or special equipment
Child disability outreach team
Direct payments or personal budgets
Foster placement
Front door for families
Family Hub support (Early Help, family coach, parenting support)
Short breaks (respite, holiday schemes)
Short breaks (residential i.e. Drove Road, Chailey Heritage)
Specialist community disability service (social worker, SWARO)
Youth offending services
Youth services (e.g. Allsorts, BYC, TDC, YMCA)
Other social worker (not disability service)

Compass Brighton & Hove Registration Form 0 to 17 years

About the person completing this form

The child or young person's details

Child or Young Person's Diversity Information

School and GP Surgery

Child or young person's diagnosis

Tell us more about the child or young person’s needs

Child or young person's diagnosis, needs and care

Child or young person's education

Services received and/or needed

About the parent carer completing the form

Communication preferences

Admin