Short Breaks Scheme Monitoring Form
To receive your second instalment for this year’s Short Breaks Scheme we require you to complete and return the form below. This will help us to understand how the payments are helping to meet the needs of children and young people with special educational needs and/or disabilities.

Please note that your next instalment will not be made until the form is completed online or returned to:

Compass Disability Services, 11-12 Belvedere Trading Estate, Taunton, TA1 1BH.

To receive the 2nd payment in September, forms need to be returned by the 31/08/2018.

1. Name of parent/carer *
Your answer
2. Name of child *
a separate form is required for each child.
Your answer
3. How did you first hear about the Short Breaks Scheme? (please tick)
4. By 31st August 2018 how much of the money paid to you in the first instalment will have been spent?
5. How has this money been spent? Please tick all that apply
6. Please describe specifically what the Payment was used for?
Your answer
7. Has the Short Breaks Scheme made it easier for your child to access short breaks?
If you ticked no, please tell us why
Your answer
8. Please rate the Short Breaks your child has accessed using the Short Breaks Scheme?
9. Overall, how would you rate the Short Breaks Scheme in Wiltshire?
10. What positive outcomes have there been for your child as a result of the Short Breaks Scheme payment?
Your answer
11. My child/young person has an EHCP.
12. What was the main reason for requesting an EHCP?
Your answer
13. My child/young person’s EHCP has made a positive difference to their life.
14. My child/young person’s annual review has really helped this year
15. What one thing would have made the biggest difference for your child moving from early years into school?
Your answer
If you would like an acknowledgement of your completed monitoring form please insert your email address in the space provided. Please allow up to 48 hours for an acknowledgement.
Your answer
Second payments will only be made after the receipt of your completed form.

If you return your form by the 31st August, you will receive the second payment in September.

The final deadline for returning your completed monitoring form is Monday 15th October – the date when this year’s scheme will close.

Your personal information will be held and used in accordance with the GDPR. The information you have provided will be used to contact you in association with Compass Disability Services activities only. It will not be used for any other purpose or shared with any other organisation without your express permission.

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