REFERRAL APPLICATION

PRE-PLACEMENTRISKASSESSEMENT

Name of Young Person:
Date of Birth:
Placing Authority:
Social worker:
Contact Number:

All young people requiring a placement should have a Risk Assessment upon admission to Elysian-Field. The purpose of this document is to make relevant professionals aware of the risks, to assess the level of risk and the probability factors, what is likely to affect those risks and how best these could be managed and reduced. This form should be forwarded to the Elysian-Field Management Team (along with other relevant reports). Under no circumstances will this form be used as a tool to specifically deny young people access to a placement with Elysian-Field.

Please fill in all sections and email to

Please do not leave sections blank put ‘not known’ if details unavailable.

KEYS:Probability Factors

Certain = Common or frequent occurrence

Probable=Likely to occur sometime

Possible=May occur sometime

Improbable=Unlikely to occur

Source

Please enter source of information substantiating the identified risks. (e.g. Review Meetings, Specific Professional Reports, Court Appearances, Previous Carers, School etc)

RISK ASSESSMENT

To be completed by Social Worker or previous Carer/’s before admission to

Elysian-Field.

Date of Assessment………………………………………………

YOUNG PERSONS DETAILS
Surname / Forenames
Other Names / Nationality
Nickname/Alias / Place of Birth
Date of Birth / Sex / Male Female
Young Person’s Home/current Address
Home Telephone No. / Mobile Telephone No.
Admission Date / Care Status / Statemented
Yes/No
Plans in place – Yes/No /
Care Plan After Care Plan Personal Education Plan
(tick boxes yes or no)
School Placement or work placement – Identified
Identified Risks (Please enter source of information and whether based on previous incidents or concerns)
To be completed before admission / Major,
High,
Moderate
or Minimal
risk / Recommended measures/action plan to reduce any risks
To be completed upon admission
1.Any physical risks the young person has presented to themselves?
(e.g. Self Harming, threats of self harming etc
Source:
Probability Factor:
2.Any physical risks the young person has presented to others?
(e.g. Violence towards peers, adults, teachers, carers or others)
Source:
Probability Factor:
3.Any risks specifically in relation to Education, work. Schools?
(e.g. Any other than in 2 above), Supervision requirements?
Source:
Probability Factor:
Identified Risks (Please enter source of information and whether based on previous incidents or concerns)
To be completed before admission / Major,
High,
Moderate
or Minimal
risk / Recommended measures/action plan to reduce any risks
To be completed upon admission
4.History of any criminal offences and nature of these?
(e.g. Any history of violence to others?
Source:
Probability Factor:
5.Any issues relating to family or members of the community?
(E.g. violent family members, friends or associates?)
Source:
Probability Factor:
6.Any concerns regarding the young person absenting themselves from accommodation workor School?
Source:
Probability Factor:
7.Any risks relating to transport issues?
Source:
Probability Factor:
8.Any Risk issues as a result of any sexually inappropriate behaviour by the young person or others?
Source:
Probability Factor:
9Any measures required addressing issues of control?
(e.g. Factors which may require more resources/facilities etc)
Source:
Probability Factor:
10.Any Risk issues as a result of drugs or solvent abuse?
Source:
Probability Factor:
11.Are there any underlying medical conditions? (e.g. ADD, Mental Health issues, Medication being taken)
Source:
Probability Factor:
Identified Risks (Please enter source of information and whether based on previous incidents or concerns)
To be completed before admission / Major,
High,
Moderate
or Minimal
risk / Recommended measures/action plan to reduce any risks
To be completed upon admission
12.Are there any Child Protection Issues?
(e.g. Outstanding Investigations)
Source:
Probability Factor:
13.Any Risk issues relating to food or drink?
Source:
Probability Factor:
14.Any other factors which should be taken into consideration?
(e.g. Any other trigger points?)
Source:
Probability Factor:
Monitoring and Review
/ Frequency / Date of next review
Name and status of person
Completing risk section of
this form.
Signature and Date
Name and Status of person
Completing Action section
Of this form.
Signature and Date
Elysian-Field Managers Signature and Date

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