RESIDENTIAL BASELINE FORM

Provider:Agreed By

Name of Young Person:Young person:

Period Covered:01/01/2000 to01/01/2000Social Worker:

Date:01/01/2000IRO:

Completed by:

Red = PoorAmber = AdequateGreen = Good

PHYSICAL HEALTH

Overall Outcome: Young Person is Physically Healthy

TARGET AREA / OUTCOME INDICATOR / RATING
R/A/G / SPECIFIC TARGETS / REVIEW DATE
Medical Care / Good standard of dental and optical Health / Please ChooseRedAmberGreen / 01/01/2000
Delivering health outcomes as per individual’s heath plan as identified at LAC review health assessment by LAC nurse / Please ChooseRedAmberGreen / 01/01/2000
Self-Care / Self-management of medical routines / Please ChooseRedAmberGreen / 01/01/2000
Development of self-care skills / Please ChooseRedAmberGreen / 01/01/2000
Positive Social Presentation / Please ChooseRedAmberGreen / 01/01/2000
Healthy Living / Exercises regularly / Please ChooseRedAmberGreen / 01/01/2000
Eats a healthy diet / Please ChooseRedAmberGreen / 01/01/2000
Understands issues relating to sexual health / Please ChooseRedAmberGreen / 01/01/2000
Abstains from solvent and drug use / Please ChooseRedAmberGreen / 01/01/2000
Reduces / abstains from smoking / Please ChooseRedAmberGreen / 01/01/2000
EMOTIONAL WELL-BEING

Overall Outcome: Young Person is Emotionally Resilient

TARGET AREA / OUTCOME INDICATOR / RATING
R/A/G / SPECIFIC TARGETS / REVIEW DATE
Resilience / Good psychological and emotional health / Please ChooseRedAmberGreen / 01/01/2000
Effective problem solving skills / Please ChooseRedAmberGreen / 01/01/2000
Able to be Creative / Please ChooseRedAmberGreen / 01/01/2000
Managing Feelings / Demonstrates self-awareness / Please ChooseRedAmberGreen / 01/01/2000
Ability to be self-disciplined and self-motivated / Please ChooseRedAmberGreen / 01/01/2000
Good communication skills / Please ChooseRedAmberGreen / 01/01/2000
Identity / Appreciates and is proud of their own race /culture / religion / community / sexuality / Please ChooseRedAmberGreen / 01/01/2000
Has a sense of belonging (to placement and family) / Please ChooseRedAmberGreen / 01/01/2000
Understands their history and story / Please ChooseRedAmberGreen / 01/01/2000
LEISURE ACTIVITIES

Overall Outcome: Young Person enjoys interests and develops confidence in their skills

TARGET AREA / OUTCOME INDICATOR / RATING
R/A/G / SPECIFIC TARGETS / REVIEW DATE
Fulfilling aspirations / has fun / Participates in cultural and sporting activities / Please ChooseRedAmberGreen / 01/01/2000
Experiences and enjoys new activities and opportunities / Please ChooseRedAmberGreen / 01/01/2000
Engages in positive leisure activities, including sports. / Please ChooseRedAmberGreen / 01/01/2000
Confidence / Develops confidence in skills / Please ChooseRedAmberGreen / 01/01/2000
Has individual goals and ambitions in life and able to express personal aspirations / Please ChooseRedAmberGreen / 01/01/2000
Community / Engaging with local community / Please ChooseRedAmberGreen / 01/01/2000
STAYING SAFE

Overall Outcome: Young Person feels safe and is safe

TARGET AREA / OUTCOME INDICATOR / RATING
R/A/G / SPECIFIC TARGETS / REVIEW DATE
Self-care /
Safety / Able to protect themselves from abuse, exploitation and victimisation / Please ChooseRedAmberGreen / 01/01/2000
Reduction /cessation of criminal activity / Please ChooseRedAmberGreen / 01/01/2000
Able to develop healthy personal relationships and protect self from domestic violence / Please ChooseRedAmberGreen / 01/01/2000
Reduction / cessation of self-harm / Please ChooseRedAmberGreen / 01/01/2000
Does not engage in dangerous behaviours / Please ChooseRedAmberGreen / 01/01/2000
Safety in Environment / Missing from Care / Reduction / abstaining from absconding / Please ChooseRedAmberGreen / 01/01/2000
Feels safe within the home / Please ChooseRedAmberGreen / 01/01/2000
Safety with Others / Does not behave in an anti-social manner / Please ChooseRedAmberGreen / 01/01/2000
Able to take responsibility for their actions / Please ChooseRedAmberGreen / 01/01/2000
LISTENED TO / PARTICIPATION

Overall Outcome: Young person is listened to and participates in decision making

TARGET AREA / OUTCOME INDICATOR / RATING
R/A/G / SPECIFIC TARGETS / REVIEW DATE
Having a Say / Being Listened to / Able to make meaningful contributions to decisions that affect their lives / Please ChooseRedAmberGreen / 01/01/2000
Able to express opinions in constructive ways / Please ChooseRedAmberGreen / 01/01/2000
Has someone independent to talk to / Please ChooseRedAmberGreen / 01/01/2000
Rights and Citizenship / Awareness of own rights and responsibilities / Please ChooseRedAmberGreen / 01/01/2000
Development of citizenship / Please ChooseRedAmberGreen / 01/01/2000
EDUCATION / TRAINING

Overall Outcome: Young person achieves educational potential

TARGET AREA / OUTCOME INDICATOR / RATING
R/A/G / SPECIFIC TARGETS / REVIEW DATE
Attendance / Attends school / college on regular basis / Please ChooseRedAmberGreen / 01/01/2000
Engages in education and is expected to achieve appropriate educational and vocational qualifications / Please ChooseRedAmberGreen / 01/01/2000
Attainment / Has good standard of Key Skills (e.g. Literacy / Numeracy) / Please ChooseRedAmberGreen / 01/01/2000
Attains qualifications and awards / Please ChooseRedAmberGreen / 01/01/2000
Attains targets set in PEP / Please ChooseRedAmberGreen / 01/01/2000
Achievement / Experiences sense of achievement / Please ChooseRedAmberGreen / 01/01/2000
FAMILY / RELATIONSHIPS

Overall Outcome: Young person has strong family and social relationships

TARGET AREA / OUTCOME INDICATOR / RATING
R/A/G / SPECIFIC TARGETS / REVIEW DATE
Contact / Regular and consistent contact with family (if appropriate) / Please ChooseRedAmberGreen / 01/01/2000
Relationships in Placement / Forms positive relationships with staff. / Please ChooseRedAmberGreen / 01/01/2000
Is an active member of home (able to be part of a team) / Please ChooseRedAmberGreen / 01/01/2000
Relationships with peers / Has meaningful and positive friendships with peers / Please ChooseRedAmberGreen / 01/01/2000
Has a strong network of support / Please ChooseRedAmberGreen / 01/01/2000
MOVING ON TO INDEPENDENCE

Overall Outcome: Young Person is well-prepared for independence / adulthood

TARGET AREA / OUTCOME INDICATOR / RATING
R/A/G / SPECIFIC TARGETS / REVIEW DATE
Preparation for Adult Life / Acquires basic skills and life skills / Please ChooseRedAmberGreen / 01/01/2000
Equipped for job seeking and able to obtain employment / Please ChooseRedAmberGreen / 01/01/2000
Young person plays an active role in planning for their future / Please ChooseRedAmberGreen / 01/01/2000
Transition / Transitions are prepared for and are predictable and smooth / Please ChooseRedAmberGreen / 01/01/2000
Transitions are consistent with level of understanding and ability of the young person / Please ChooseRedAmberGreen / 01/01/2000