Staged Assessment & Intervention Form(June 2013)

REFERRAL DETAILS

Referral initiated by
Role/Organisation:
Telephone No/email:
Address:
Date of completion:
Named Person (if different from above):
Lead Professional (if different from above):
2. CHILD OR YOUNG PERSON’S DETAILS
Child/young person’s name:
Also known as:
Date of Birth:
Gender: Male  Female 
Health Visitor (for pre-school children):
Nursery/School: / Address:
Postcode:
Telephone nos. (include mobile):
Religion:
Ethnicity:
Preferred Language

3. PARENT OR PRINCIPAL CARER’S DETAILS
Parent or principal carer’s name:
Address (if different from Section 2):
Postcode: Telephone nos. (include home/work/mobile):
4. OTHER PARENT OR PERSON WITH PARENTAL RESPONSIBILITIES DETAILS
Other parent/person with parental responsibilities name:
Address:
Postcode: Telephone numbers (include home/work/mobile):
5. DETAILS OF OTHER ADULTS IN HOUSEHOLD, TOGETHER WITH ALL CHILDREN AND YOUNG PEOPLE. INCLUDE SIGNIFICANT OTHERS.
Name / Age/DOB / Relationship to child
6. OTHER AGENCIES IN CONTACT WITH THE CHILD/FAMILY
(INCLUDE COMMUNITY RESOURCES AND AGENCIES WITH SIGNIFICANT PREVIOUS INVOLVEMENT):
Agency / Name / Address/contact details (include postcode and phone number) / Dates to and from, or current/previous involvement

General Practitioner

7.SUMMARY OF CONCERNS & BRIEF DESCRIPTION OF INTERVENTIONS TO DATE. INCLUDE WHAT WORKS/WHAT’S GOING WELL
(Make reference to relevant wellbeing indicators)
safe / healthy / achieving / nurtured / active / respected / responsible / included
8. ANY OTHER RELEVANT INFORMATION?
9. WHO NEEDS TO BE INVITED TO THE STAGED ASSESSMENT AND INTERVENTION MEETING? This section is needed specifically for Early Years SAI Meetings (formerly EYCAT), as these are organised through central admin
Agency / Name / Contact Details
9. CHILD/YOUNG PERSON’S & PARENTS/CARERS VIEWS:
10. WHAT OUTCOMES ARE EXPECTED?

12. CONSENT TO REFERRAL & INFORMATION SHARING:

I agree to a referral being made for and information being shared with doctors, teachers, health visitors, school nurses, social workers, and agreed others. I understand that I may change my mind about this at any time. If I do, I will advise my support worker.
I understand that the information shared will be used to provide health, education and welfare services in the best interests of my child/ me.
I understand that personal records are protected by various laws and cannot be disclosed without written consent, unless otherwise authorised (in cases where someone is at serious risk). I have received and understand information on confidentiality and information sharing.
PERSON(S) WITH PARENTAL RESPONSIBILITIES
Consent to referral being made and to information being shared
Signature:
Name:
Date:
Signature:
Name:
Date: / CHILD/YOUNG PERSON:
I agree to this referral being made and to information being shared between relevant people. I understand that I may change my mind about this at any time. If I do, I will tell my support worker/contact person as soon as possible.
Signature:
Name:
Date: