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Early Help Assessment - Part 1 & ConsentPrivate & Confidential
Family DetailsPlease note: This is an electronic form
Family Surname(s):
Enter family surname(s)
Main Address & Contact Details
House/Flat Number/Name:
Enter Number/Name
Street/Location Name:
EnterStreet/Location
Village/Town/City:
Enter Village/Town/City / Post Code:
Enter Postcode / Main Telephone Number:
Enter tel. no.
Mobile Number:
Enter mobile no.
Email:
Enter email address
Family Members
Full Name / Date of Birth / Gender / Nursery/School/College/Place of work. / Relationship / Ethnic Origin
Enter Name / DoB / Gender / Enter Setting / Relationship / Ethnicity /
Enter Name / DoB / Gender / Enter Setting / Relationship / Ethnicity /
Enter Name / DoB / Gender / Enter Setting / Relationship / Ethnicity /
Enter Name / DoB / Gender / Enter Setting / Relationship / Ethnicity /
Enter Name / DoB / Gender / Enter Setting / Relationship / Ethnicity /
Enter Name / DoB / Gender / Enter Setting / Relationship / Ethnicity /
Enter Name / DoB / Gender / Enter Setting / Relationship / Ethnicity /
Information Sharing & Consent
Signed consent must be obtained with all Early Help Assessments.
For your Family - Please read the information section whichaccompanies the Early Help Assessment.
  • This form belongs to your family. It is to help you record information and make a plan. The information you share with us will not be shared with anyone else without your consent unless you are in danger.
  • You should keep the original copy of this form. Keep in a safe place with other important documents.
  • You can withdraw consent for support from Early Help at any time.

I/We have read the information on the accompanying guidance sheet and agree to copies of my Early Help documentation being sent to, and stored safely with Herefordshire Council’s central database. Your information will be stored securely for a 6 year period, following the closure date of the case with Early Help.
Your information may also be shared with partner organisations, such as, Children Centres, early years providers, health professionals and other agencies involved in supporting families through Herefordshire’s Families First initiative. Please tick/cross box if you agree. / ☐ /
Is there any individual person or agency/setting you do not wish information to be shared with? / Yes / No (if yes, please provide details here)
Enter details here
Please tick/cross the support option(s) below that are most suitable for your family:
I agree to the Early Help Assessment taking place and for the information to be shared at a Family Network Meeting.
Please tick/cross box if you agree. / ☐ / I agree to the Early Help Assessment taking place and for the information to be shared at a Team Around the Family (TAF) Meeting.
Please tick/cross box if you agree. / ☐ /
Name
(Parent/Guardian/Young Person) / Signature(required) / Date
Enter/print name here / Enter date /
Enter/print name here / Enter date /

Herefordshire Early Help Assessment Version 3. September 2018Private & Confidential

1

Summary of Presenting Needs
Please tick all that are appropriate
This section helps families and professionals to think about their areas of need and the services which can potentially offer support.
1. Crime & Anti-Social Behaviour / 3. Children who may need help / 5. Domestic Violence & Abuse
Child involved in crime in the last 12 months. / ☐ / A child identified as needing Early Help / Family Support / Children’s Centre Services. / ☐ / Young person / Adult experiencing/ or at risk of Domestic Abuse / Domestic Violence. / ☐
Adult/Child involved in Anti-Social Behaviour in last 12 months. / ☐ / A child assessed by Social Care as needing Early Help / Family Support. / ☐ / Young person / Adult involved in Domestic Abuse / Domestic Violence - in last 12 months. / ☐
Adult due for parole within 12 months with parental responsibility. / ☐ / Failure to respond to emotional needs. / ☐ / Household involved in police response for Domestic Abuse / Domestic Violence in the last 12 months. / ☐
Adult on Licence/ Supervision / Community Order / Suspended Sentence with parental responsibility. / ☐ / Failure to respond tophysical needs. / ☐ / 6. Health Wellbeing
Adult / Child involved in offending behaviour. / ☐ / Child Sexual Exploitation (CSE) concerns. / ☐ / Adult / Child with mental or emotional health difficulties. / ☐
2. School Attendance Issues / Adult/Child Disability. / ☐ / Adult / Child with substance or alcohol related issues. / ☐
Child with attendance issues. / ☐ / 4. Risk of financial exclusion or worklessness / Adult Carer.
Young Carer. / ☐
☐
Child in receipt of 3 fixed term exclusions or has been permanently excluded. / ☐ / Adult in receipt of benefits/universal credit. / ☐ / Adult/Child with one or more other health concerns.
- Access to dental healthcare.
- Enhancing Communication.
- Healthy lifestyles.
- Other health concerns. / ☐
☐
☐
☐
Child in educational provision for behavioural difficulties. / ☐ / Child / Young Person identified as being Not in Education or Employment (NEET) or potentially NEET. / ☐
Child not registered with a schoolor alternative educational provision. / ☐ / Family at risk of financial exclusion or housing difficulties / homelessness. / ☐ / Missed appointments with medical professionals. / ☐
Have any other assessments been completed with a family member?
[E.g. CSE Screening Tool, Graded Care Profile etc.] / Enter assessment details here, including information on who was included in any assessments and dates undertaken.
Presenting Needs & Additional Information
Enter details around why Part 1 is being completed. Information included should link to the presenting needs highlighted above. Additional information can also be added here (e.g. other family members). /
Outcome of Part 1:
Choose an Outcome. / Enter brief outcome details if required here /
Details of Person Completing the Form(when completing Part 1 only)
Please enter the details of the Key Person undertaking the Early Help Pre-Assessment
Name:
Enter Person name
Phone:
Enter phone number / Role/Setting:
Enter role / setting
Email:
Enter email address / Date:
Enter date
Early Help Assessment - Part 2
Please refer to the Information & Guidance pages for prompts and direction on the completion of all sections in Part 2 of the Early Help Assessment.
Details / information of other significant persons not listed above. This can include names of Partners, Grandparents or other significant addresses:
Enter names, addresses etc. here
If Child Sexual Exploitation (CSE) is a concern, has the CSE Screening Tool been completed? / Yes / No /
If issues around neglect have been identified, has a Graded Care Profile been completed with the family? / Yes / No /
If a disability has been identified within the family, please provide details below:
Enter details of disability here
Other Professionals supporting the family?
Enter details of Professionals involved here
Is an Interpreter required to complete the full Assessment?
Yes / No / Enter language details /
Child DevelopmentEnter details for each Child/Young Person
Health / Education / EmotionBehaviour / Identity / Relationships / Presentation / Abilities & Skills
Enter details about Child Development here
Family & EnvironmentEnter details for each Child/Young Person
Social Interaction / Income / Employment / Housing / Family History / Family Functioning
Enter details about Family & Environment here
ParentingEnter details for each Child/Young Person
Parenting / Basic Care / Safety / Warmth & Love / Stimulation / Guidance & Boundaries / Stability & Security
Enter details about Parenting here
Strengths & WorriesEnter details for each Child/Young Person
Strengths / Worries & Concerns / Protection / Co-operation / Motivation / Family Plans for Future
Enter details about Strengths & Worries here
Family Voice
As a family, is there anything else you would like to add to this assessment that has not been covered or that you would like to comment on?
Child/Young Person Voice:
Child/Young Person can enter own voice information here
Adult Voice:
Adult can enter own voice information here
Is a referral to Children’s Social Care (Level 4) required as a result of completing the Early Help Assessment?
Please consult the Levels of Need Guidance for support.
Link: Herefordshire Levels of Need Guidance / Yes / No
Agreed Actions for Support
Please provide a Families First indicator and outcome for each support outcome/action. Refer to the Families First guidance for information on indicators and outcome codes. Link:Families First Guidance Document
FF Indicator & Outcome Code / Desired Outcomes / Action / Who will do this? / By when?
Ind / Out
Out
Out / Enter outcome / Enter Action / Enter person/setting / Enter date /
Ind / Out
Out
Out / Enter outcome / Enter Action / Enter person/setting / Enter date /
Ind / Out
Out
Out / Enter outcome / Enter Action / Enter person/setting / Enter date /
Ind / Out
Out
Out / Enter outcome / Enter Action / Enter person/setting / Enter date /
Ind / Out
Out
Out / Enter outcome / Enter Action / Enter person/setting / Enter date /
Ind / Out
Out
Out / Enter outcome / Enter Action / Enter person/setting / Enter date /
Ind / Out
Out
Out / Enter outcome / Enter Action / Enter person/setting / Enter date /
Ind / Out
Out
Out / Enter outcome / Enter Action / Enter person/setting / Enter date /
Agreed review date:
Enter review date /
Key Person
Please enter the details of the Key Person involved in the Early Help Assessment
Name:
Enter Person name
Phone:
Enter phone number / Role/Setting:
Enter role/setting name
Email:
Enter email address / Date:
Enter date

I/we agree this Early HelpAssessment is an accurate summary of my / our family’s situation.

Name / Parent/Carer/Young Person
Signature(s) / Date
Enter/print name here / Enter date /
Enter/print name here / Enter date /

Herefordshire Early Help Assessment Version 3. September 2018Private & Confidential