This form is to be used to provide a holistic agency contribution to assessments, child protection conferences or LAC reviews (delete as applicable). The headings reflect the domains and dimensions of the assessment framework. Agencies should complete all the sections where they have any knowledge from their agency perspective. The contribution will be included in the complete assessment being compiled by the social worker, or will be shared at the child protection conference or LAC review. Please also refer to attached notes to aid any contribution made.
/ Name of child/young person: / (Date of Birth )Family address:
If information is primarily about an adult in the child/young person’s family, give name and relationship to child:
Agency providing the information:
Form completed by:
Designation:
Location:
Telephone Number:
Please complete as much information as possible from your own knowledge/records for each of the domains and dimensions of the assessment and attach any relevant reports.
List significant contacts with child/young person and/or family members – date, reason and outcome (attach chronology if available):
Family History & Functioning/Wider Family/Housing/Employment/Income/Family's Social Integration/Community Resources
CHILD’S DEVELOPMENTAL NEEDS
/ Child/Young Person’s EducationDoes the child have an effective, high quality Personal Education Plan (PEP)?
Please attach a copy. / YES/NO
Does the child have special educational needs (SEN)? / YES/NO
What stage of Code of Practice?
Please attach the most recent IEP or Statement of SEN.
Does the child attend school regularly: / YES/NO
Have they missed more than 25 days schooling in the last year. / YES/NO
Do they have any behavioural difficulties? / YES/NO
Have they been excluded? If yes, for how many days:
Any other educational issues, strengths, difficulties? Please include level of attainment. How are the child’s needs supported in school?
Child/Young Person’s Health
/ Is the child fit and well?If not, please specify: / YES/NO
Is child/young person in receipt of hospital or other medical services?
If yes, please specify: / YES/NO
Name of Paediatric/Hospital Consultant
Any other health issues, strengths, difficulties:
Disability
Is the child/young person disabled?
If yes, please state the nature of the disability from your agency perspective and the child’s needs: / YES/NO
Please complete and return this contribution to the Assessment and return it to the Social Worker within 14 days of receipt. CONFIDENTIAL
Current Family & Home SituationPlease draw or capture the family structure and who the child/young person lives with and does not live with, including siblings, other significant adults and carers.
Significant events that have affected this child & family
Describe a day in the life of the child/young person
Consider how identity & culture may impact on his/her life
Strengths/Resources
Worries/Concerns/challenges
Health & Well Being
Strengths/Resources
Worries/Concerns/challenges
Development, Educational Attainments & Achievements
Strengths/Resources
Worries/Concerns/challenges
Parenting /Caring Capacity
Strengths/Resources
Worries/Concerns/challenges
Family & Community
Strengths/Resources
Worries/Concerns/challenges
Child/young person views of what is happening in their life
Parent/carer(s) views of what is happening in the child/young person’s life
What is your analysis of the impact/risk to this child/YP - What needs to change & why
Agency Involvement/Plans
Please summarise current agency involvement and plans for work with the child/young person
Name and signature of all contributors:
Please state if this contribution has been collated on behalf of a number of staff in your agency. If yes, please give their name, position and signature:
Name / Signature / Position / Date
Please note that the contents of this form will usually be shared with the family concerned when the Multi-Agency Assessment is completed.
Please complete and return this contribution to the Assessment and return it to the Social Worker within 14 days of receipt. CONFIDENTIAL