Classification: OFFICIAL

Placement Request for Accommodation & Support for 16/17yr olds

Please note:

  • For Emergency Requests: Sections 1 – 3 of the form must be completed for a trawl to commence. Completion of the remainder of the form can be sent through after trawl has commenced.
  • For Standard Requests: Sections 4-12 of the form must be completed for a trawl to commence.
  • The information that you put in this referral will form the basis of the contract that we have with the provider therefore please ensure the information is accurate and includes everything that you are expecting from the placement.

Referred by: / Date of Referral:
Job Title& Team / Contact No &E-mail Address
Team Manager / Contact No & E-mail Address
Name and address of School / College / School / College Year
SEN Status: / Date of last SEN review
Name
Current Address of Young Person / Gender
Date of Birth / Age
Ethnicity/Religion / First
Language
Legal Status / CCM No:
Reason for Placement Request / Change of Placement / Support Package:
Section 1: Details about the placement being requested
Estimated Duration of Placement:
(please delete options that do not apply) /
  • Respite
  • Short Term (up to 6 months)
  • Long Term (over 6 months)

Timescales within which placement is required to commence:
(please delete options that do not apply) /
  • Emergency Placement
  • Planned Placement

Proposed Placement Start date:
Location of placement being requested:
(please delete options that do not apply) /
  • Within Derby City
  • Within a 20 mile radius of Derby City
  • Outside Derby City

Preferred Type of Accommodation (please delete options that do not apply) /
  • Shared occupancy
  • Solo occupancy

What level of placement is required to meet the needs of the Young Person?
(please delete options that do not apply)
Core Level–Accommodation only / Yes No
Core Level –Accommodation with a support package of up to 5hrs per week / Yes No
PLEASE STATE
Number of Support Hours …………………..
EnhancedLevel - A flexible package of between 6 -20 hours per week floating support / Yes No
PLEASE STATE
Number of Support Hours …………………..
ComplexLevel - 24/7 support on site / Yes No
Is the Young Person entitled to Housing Benefit? / Yes No
Please provide details of the young person’s wishes and feelings about what type of placement they would like?
Section 2: Parental Details
Name and Full Address / Relationship Parental
Responsibility?
Yes No
Yes No
Please provide details of the parent’s feelings and wishes?
Other Significant Adults:
Name and Full Address / Relationship Parental
Responsibility
Yes No
Yes No
Section 3: Risk Assessment in relation to young person:
Are there any risks maintaining the current placement? / Yes No
If Yes please specify
Are there any risks implementing a change of placement? / Yes No
If Yes please specify :
Are there any geographical areas that would be a risk to the Young person? / Yes No
If Yes please specify the areas:
Is the young person known to abscond / wander off? / Yes No
If Yes please specify risk management strategies:
Are there any risks to the Young Person from the Parents / Other Significant Adults? / Yes No
If Yes please provide detail:
Can the Young person be placed with other Young People? / Yes No
If No please specify why:
Is the Young person physically or verbally aggressive towards adults or others? / Yes No
If Yes please specify:
Has the Young person been sexually abused or are they vulnerable to sexual abuse? / Yes No
If Yes please specify:
Does the Young person display sexualised behaviour? / Yes No
If Yes please detail how this risk is managed:
Does the Young person have a history of fire setting? / Yes No
If Yes please specify
Has there been any incident (s) of self-harm/suicide or is the Young person vulnerable to this? / Yes No
If Yes please specify:
Does the Young person have any issues with alcohol/substance misuse? / Yes No
If Yes please specify:
Has the Young person been involved in any violent/offending behaviour or are they vulnerable to this? / Yes No
If Yes please specify:
Does the Young person display any racist behaviour? / Yes No
If Yes please specify:
Any other known risks that will need to be managed in the placement? / Yes No
If Yes please specify:
Section 4 Contact Requirements
Will the young person have contact? / Yes No
Please provide the name and address of where contact will be held?
Is contact scheduled to be supervised or unsupervised? / Supervised Unsupervised
What is the expected frequency of contact?
Please state what time contact will start and end?
Section 5 Please provide a current pen picture of the Young Person
-Likes/Dislikes
-Hobbies / Interests
-Personality
-Ability to interact with adults and other young people
-Level of supervision required (e.g. normal for age or higher)
Section 6: Intervention and Support
Are any other agencies involved with this young
person? e.g. CAMHS, YOS, Health, FIP etc / Yes No
If Yes, please provide details of the agencies, and what support has been provided, including current care package:
Section 7: Additional Family Members
Is the young person part of a sibling group? / Yes No
Details of siblings
Name / Age / Accommodated Y/N / In house / name of provider / Current town of placement
Section 8: Placement History
Has this young person been looked after previously? / Yes No
Date from / Date to / Type of placement / Provider / Why placement ended
Please provide details of any Problems / Challenges from previous placement(s)
Any other information regarding Current Circumstances or Family History
Section 9: Health and Emotional Wellbeing of Young person
Name and Address of GP
Any Diagnosed medical conditions? / Yes No
Details
Is the young person currently on medication? / Yes No
Details
Are there any medical protocol(s) in place for the young person (ie. epilepsy management) / Yes No
Details
Does the young person require a manual handling plan? / Yes No
Details
Are there any Medical appointments booked for the young person? / Yes No
If Yes, please provide details
Does the young person have any allergies / fears / phobias? / Yes No
If Yes, please provide details
Does the young person smoke? / Yes No
Does the young person have permission to smoke? / Yes No
Most recent statutory health assessment
Date / Type of Assessment / Examining Practitioner
Does the young person have a specific disability? / Yes No
Details
Is the young person registered disabled? / Yes No
Details
Has the young person been referred for any specialist services (e.g. CAMHS / CTPLD)? / Yes No
Name of specialist service / Date(s) / Details
Presenting Behaviour / Needs on referral
Details
What was the outcome of the CAMHS / CTPLD referral? / Date of Referral
Assessing Practitioner / Date of Assessment(s)
Details
Does the young person have any assessed therapeutic needs?
e.g. attachment disorders / Yes No
Details
Has the young person had any other specific assessments? / Yes No
Date(s) / details
Does the young person have a health care plan? / Yes No
If No, please state the reason(s) why
Are the /young person’s developmental checks up to date? / Yes No
If No, please state the reason(s) why
Has the young person received an annual sight test? / Yes No
If No, please state the reason(s) why
Has the young person received a 6 monthly dental check? / Yes No
If No, please state the reason(s) why
Are the young person(s) immunisations up to date? / Yes No
If No, please state the reason(s) why
Does the young person have any specific medical / care needs / current treatment? / Yes No
If Yes, please specify
Does the young person have any specific dietary / nutritional needs? / Yes No
If Yes, please specify
Section 10: Education / Employment / Training of the Young Person
Is the young person in education / employment / training or none of the above?
How many hours per week?
Days and times of attendance at education/ employment or training provision?
Does the young person have any history of Refusals / Exclusions? / Yes No
Establishment / Reason / Date From / Date to
Does the young person have any diagnosis of a Learning Disability / Difficulties? / Yes No
If Yes please specify
Has the young person had any involvement with the Virtual School? / Yes No
If Yes please specify
Does the young person have a Personal Education Plan (PEP) / Yes No
If Yes please specify
Does the young person have a statement of Special Educational Needs (SEN)? / Yes No
If Yes please specify
Has a referral been made for SEN? / Yes No
If Yes please specify
Is the young person able to form social relationships with peers? / Yes No
If No please specify
Section 11: Culture / Heritage / Diversity
Have any specific needs been identified for the young person regarding:
Personal Care / Yes No
Religion / Yes No
Tradition / Yes No
Clothing / Yes No
Diet / Yes No
Other (Please specify) / Yes No
Has any work been started with the young person to address issues of identity (including disability, faith, culture, sexuality, etc.)? / Yes No
If Yes to any of the above, please specify
If NO is there a need for any of this work? / Yes No
Does the young person have a religion? / Yes No
If YES please specify :
Does the young person speak fluent English? / Yes No
If NO please specify which language(s) they speak fluently
Details
Is this young person an unaccompanied minor (UASC)? / Yes No
Section 12: Financial Authorisation
Please only complete this section if you have attended the MARP to obtain your authorisation
Date of Panel / Panel Chair
Please provide a summary of agreed actions for this placement.
Agreed length of placement
If this is an emergency placement request please ensure that you have Service Director Approval and that you Head of Service completes the details below

I confirm that I have read the details contained within the referral, and discussed this case, with the Case Accountable Worker.

I authorise a placement for the above named Young Person, as they have reached the threshold to Become Looked After / require a placement move.

Authorised by
Position
Date

Classification: OFFICIAL

Placement Team Form (