(supported by stand-alone UHA Action Plan, spanning this and any subsequent UHA Reviews, through to UHA closure.)
FOR RECEIVING AGENCIES ONLY: UHA Received by
Name: / Agency: / Job Title: / Telephone:
Date Received: / Time:
1. Details of PRACTITIONER undertaking this UHA (details required so you can be contacted if further information needed, or to discuss further actions)
Name of Assessor: / Job title: / Agency: / Date of UHA:
Address: / Post Code: / Tel/Mobile: / Email:
2. CHILD(REN)/YOUNG PERSON'S details (including those not in the home)
Last Name / First Name / AKA* / Age/SchYr / DOB/EDD** / M/F / Ethnicity (refer codes) / Address *** / Post Code / Tel/Mobile/Email
(*Also Known As) (**Date of Birth/Estimated Date of Delivery) (***Only record where different)
3. Child/Young Person’s PRINCIPAL CARERS
Carer
Last Name / Carer
First Name / (Age or
DOB) / Parental Responsibility? / M/F / Ethnicity / Relationship to which child/ren / Address
(if different from that of child) / Tenancy
Type / Post Code / Tel/Mobile/Email
4. OTHER HOUSEHOLD MEMBERS or SIGNIFICANT PEOPLE IN THE CHILD/YOUNG PERSON’S LIFE (where known)
Last Name / First Name / Age/SchYr / DOB/EDD / M/F / Ethnicity / Relationship to child (include address ) / Comment, where appropriate
5. Other professionals CURRENTLY involved (to include GP and nursery/pre-school/school/college details) (For additional professionals, list on separate page.)
Last Name / First Name / Job Title/Role / Team/Agency / Working with which family member? / Tel/Mobile / Email
6. Has there been PREVIOUS Statutory, Specialist or Voluntary Sector involvement? (If so, include relevant information in Section 10)
Children’s Social Care CSC / No / Yes / Not Known / Education Welfare Service EWS / No / Yes / N/K
Child and Adolescent Mental Health Service CAMHS / No / Yes / Not Known / Youth Justice Service YJS / No / Yes / N/K
Special Educational Needs or Disability/Sch Action Plus
Educational Psychology / Sensory Impairment / No / Yes / Not Known / Police/Probation / No / Yes / N/K
Family Matters / No / Yes / Not Known / Housing / No / Yes / N/K
Other Specialist Health Service / No / Yes / Not Known / Other interventions: (e.g. Anti-social behaviour; IDVA; )
Adult Services – (Mental Health / Drug - Alcohol Abuse / Disability /DV / Housing / Specialist Health / Vulnerable People’s Services / other ) / No / Yes / Not Known
(N/K)
7. Has a previous UHA or Common Assessment Framework (CAF) been completed? / No / Yes / If yes, please attach (or summarize below)
8. Particular issues for consideration
Does the child and/or other family member have a disability or special needs? If Yes, provide outline detail? / Child
Carer
Other / Y / N
Y / N
Y / N / If Yes, provide detail:
/ Are there any Immigration Status issues for any family members? If Yes, indicate who’s affected and how. / Yes / No
If Yes, provide detail: / Are there any interpreting / communication needs for the child and/or family? Indicate who is affected. / Yes / No
If Yes, provide detail:
First Language:
Is anybody above a Teenage Parent, or in Teenage Pregnancy situation? Yes / No
If Yes, include details within form. / Is any child acting as a Young Carer?
Yes / No
If Yes, include details within form. / Is any child/young person above in a Private Fostering* arrangement? Yes / No
If Yes, include details within form, and copy UHA to MASH
School Attendance level / P/T Timetable / Y/N / Exclusion / Y/N / Parental workless / Y/N / Offending / Y/N
9. BACKGROUND OVERVIEW: What has led to this child unborn baby, infant, child or young person being assessed at this time?
(where there is more one child, insert each child’s name as prefix to identify which paragraph is relevant to which child in the information below)
Identify whether any of the following Trigger Trio apply?
(See supporting Guidance Sheet for further information) / Domestic Violence
Child Parent Other / Drug or Alcohol Abuse
Child Parent Other / Mental Health
Child Parent Other
Outline what your concerns are: - what is not working so well? - what has already been tried? - what still needs to change?
10. INFORMATION GATHERING – to support this ASSESSMENT. Strengths and Needs outlined. (Further on each of the headings summarized in supporting Guidance.)
(where there is more one child, insert each child’s name as prefix to identify which paragraph is relevant to which child in the information below)
Development of the unborn baby, infant, child or young person:
Child’s Health: General Health; Physical and Sensory Development; Child or Young Person’s Mental Health
Evidence of STRENGTHS / Evidence of Issues or CONCERNS
Emotional, Social and Behavioural Issues
Evidence of STRENGTHS / Evidence of Issues or CONCERNS
Identity; Independence; Social Presentation; Family and Social Relationships
Evidence of STRENGTHS / Evidence of Issues or CONCERNS
Learning: Understanding, Reasoning; Participation; Speech, Language and Communication; Progress and Achievement in Learning; Aspirations
Evidence of STRENGTHS / Evidence of Issues or CONCERNS
Parents and Carers – impact of parenting capacity on child or young person’s well being:
Basic Care, ensuring Safety and Protection; Emotional Warmth and Stability; Guidance, Boundaries and Stimulation, Relationship Stability between Parents/Carers
Evidence of STRENGTHS / Evidence of Issues or CONCERNS
Family and Environment – factors that impact on child or young person’s well-being:
Family History, Functioning and Well-Being; Wider Family; Housing, Employment, and Financial Considerations; Social and Community Resources
Evidence of STRENGTHS / Evidence of Issues or CONCERNS
12. Analysis of information gathered above to identify in particular what now needs to change in the family / for the child/ren
(where there is more one child, insert each child’s name as prefix to identify which paragraph is relevant to which child in the information below)
What needs to Change? / Priority
(1,2,3) / What support is needed to effect change / How will you know when the change has been achieved?
What will it look like? How will things be different?
NOW COMPLETE THE SUPPORTING STAND-ALONE ACTION PLANNING* SHEET WITH DETAILS OF WHO WILL LEAD ON WHICH ACTION; WHAT THEY WILL DO; AND BY WHEN?
* Action Planning form complements the UHA, being updated through all Reviews, throughout the UHA episode through to closure.
13. Child or Young Person’s COMMENT on the assessment - and on actions identified on supporting stand-alone Action Plan
14. Parent or Carer’s COMMENT on the assessment - and on actions identified on supporting stand-alone Action Plan
15. Consent Statement for Information Storage / Information Sharing in relation to this UHA, including supporting stand-alone Action Plan.
(Please note that consent must be gained unless obtaining this consent would place the child at risk of harm)
We need to collect the information in this Universal Help Assessment (UHA) record so that we can understand what help you may need. If we cannot cover all your needs we may need to share some of this information with other services so that they can provide the support you need. We will otherwise treat your information as confidential and we will not share it with any other organisation unless you either consent, we are otherwise permitted to by law or unless you or any other person will come to some harm if we do not share it. In certain circumstances, information may be shared with relevant partner agencies, including the police, children’s services authorities, Clinical Commissioning Groups and the NHS Commissioning Board to ensure that the welfare of children is safeguarded. In any case, we will only share the minimum information we need to share. Anonymised data from your record may also be used to help us monitor and improve those services in the future.
I understand that information recorded on this UHA (including related Action plan) will be stored and used for the purpose outlined above.
Parent/Carer Signature / Date
Parent/Carer Signature / Date
Have parents/carer(s) given consent for this UHA? / No / Yes / Parent/Carer Signature / Date / / / 2014
Has the young person given consent for this UHA? / No / Yes / Young Person’s Signature / Date / / / 2014
If consent has not been obtained, please explain the exceptional circumstances which prevail which allow information to be shared without this consent.
Completed copy to be securely shared with family and all involved agencies:
If you have child protection concerns, follow MASH procedures