Personal Details

Young Person's name

DOB

Gender

Male

Female

Place of birth

Ethnic origin

Religion

First language

Name, address and telephone number of parents/guardians

Young person's current address and telephone number

Name of primary carer

Reason why placement is required?

Legal status

Referral

Date received

Persons name

Position who is making the referral

Person receiving referral

Telephone number

Social worker

Responsible authority

Address

Date accommodation is required

Information required on admission

Background details

Date of care order or request for accommodation?

Grounds for care order or reasons for the accommodation?

Family details

Mother's Name

DOB:

Address and telephone number:

Areas of Risk or Concern?

Father's Name

DOB:

Address and telephone number:

Areas of Risk or Concern?

Siblings

Name of Sibling	DOB	Address
			Add sibling

Other significant adults

Name	Relationship/Parental responsibility	Address
			Add other

Behaviours presented by young person

Education

Name and address of current education establishment?

Telephone number

Contact name

Managers name

Has a Personal Education Plan been completed?

The review date and arrangements?

Is the young person in need of special education under the terms of The Educational Act 1981

If Yes, what date was this completed?

Named person and contact point of person responsible for the statement

Date and arrangement for review

EHC Plan in place?

Details of any other agencies involved with education, such as child guidance

Has any psychiatric/psychological assessment been made?

Yes

No

Name of originator, date of assessment

Is process in progress/being considered

Health

Does the young person suffer from any allergies?

Are there any pending health appointments?

Are there any specific health care requirements?

Are there any specific dietary needs?

Has the young person been seen by a psychiatrist or psychologist? Report Accessed?

Does the young person have any mental health provision that is likely to continue at new placement?

Specific Information

Details of any criminal behaviour / pending court appearances

Date	Offence	Heared or to be heared at	Desposal Sentence
				Add specific

Court orders currently affecting the child

Date	Reason	Type Of Order	Duration
				Add court

Present situation

Current attitude/level of self esteem

Likely effect on peer group

Likely attitude towards staff (male/female)

Ability to adapt to new situations

Ability to communicate (verbally or otherwise)

Interests/hobbies

What are the young persons views regarding and independence placement

Willingness to participate in structured individual programme

Experience of outdoor activities

Social Care Requirements

In what way can this placement help the young person to develop?

How do you think the young person will respond to this placement?

Has the young person got a current Pathway Plan/do they require one?

What is the current long-term plan for this young person? Request in updated Care Plan

Has the young person an Independent Visitor, Mentor or Advocate?

What are the specific areas and behaviour you would like us to address?

What would you like the young person to achieve from this placement?

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