REFERRAL APPLICATION
&
PRE-PLACEMENT RISK ASSESSEMENT
Name of Young Person:
Date of Birth:
Placing Authority:
Social worker:
Contact Number:
1
2
All young people requiring a placement should have a Risk Assessment upon
admission to Elysian-Field. The purpose of this document is to make relevant
professionals aware of the risks, to assess the level of risk and the probability
factors, what is likely to affect those risks and how best these could be
managed and reduced. This form should be forwarded to the Elysian-Field
Management Team (along with other relevant reports). Under no
circumstances will this form be used as a tool to specifically deny young people
access to a placement with Elysian-Field.
Please fill in all sections and email to hello@elysian-field.co.uk
Please do not leave sections blank put ‘not known’ if details unavailable.
KEYS:
Probability Factors
Certain
=
Common or frequent occurrence
Probable
=
Likely to occur sometime
Possible
=
May occur sometime
Improbable
=
Unlikely to occur
Source
Please enter source of information substantiating the identified risks. (e.g. Review
Meetings, Specific Professional Reports, Court Appearances, Previous Carers, School
etc)
RISK ASSESSMENT
To be completed by Social Worker or previous Carer/’s before admission to
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Elysian-Field.
Date of Assessment………………………………………………
YOUNG PERSONS DETAILS
Surname
Forenames
Other Names
Nationality
Nickname/Alias
Place of Birth
Date of Birth
Sex
Male
Female
Young Person’s Home/current
Address
Mobile
Home Telephone No.
Telephone No.
Admission Date
Plans in place – Yes/No
Statemented
Care Status
Care Plan
Yes/No
After Care Plan
Personal Education Plan
(tick boxes yes or no)
School Placement or work placement – Identified
Identified Risks (Please enter source
Major,
Recommended
of information and whether based
High,
measures/action plan
on previous incidents or concerns)
Moderate
to reduce any risks
To be completed before admission
or
To be completed upon
Minimal
admission
risk
1.
Any physical
risks the
young person has
presented to
themselves?
(e.g. Self Harming, threats
of self harming etc
Source:
Probability Factor:
4
2.
Any physical
risks the
young person has
presented to
others?
(e.g. Violence towards
peers, adults, teachers,
carers or others)
3.
Source:
Probability Factor:
Any risks
specifically in
relation to
Education, work.
Schools?
(e.g. Any other than in 2
Source:
above), Supervision
requirements?
Probability Factor:
Identified Risks (Please enter source
Major,
Recommended
of information and whether based
High,
measures/action plan
on previous incidents or concerns)
Moderate
to reduce any risks
To be completed before admission
or
To be completed upon
Minimal
admission
risk
4.
History of any
criminal offences
and nature of
these?
(e.g. Any history of
violence to others?
Source:
Probability Factor:
5
5.
Any issues
relating to family
or members of
the community?
(E.g. violent family
members, friends or
associates?)
6.
Source:
Probability Factor:
Any concerns
regarding the
young person
absenting
themselves from
accommodation
Source:
work or School?
Probability Factor:
7.
Any risks relating
to transport
issues?
Source:
Probability Factor:
8.
Any Risk issues
as a result of any
sexually
inappropriate
behaviour by the
young person or
others?
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Source:
Probability Factor:
Any measures
required
addressing issues
of control?
(e.g. Factors which may
require more
resources/facilities etc)
10.
Source:
Probability Factor:
Any Risk issues
as a result of
drugs or solvent
abuse?
Source:
Probability Factor:
11.
Are there any
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underlying
medical
conditions?
(e.g. ADD, Mental Health
issues, Medication being
taken)
Source:
Probability Factor:
Identified Risks (Please enter source
Major,
Recommended
of information and whether based
High,
measures/action plan
on previous incidents or concerns)
Moderate
to reduce any risks
To be completed before admission
or
To be completed upon
Minimal
admission
risk
12.
Are there any
Child Protection
Issues?
(e.g. Outstanding
Investigations)
Source:
Probability Factor:
7
13.
Any Risk issues
relating to food
or drink?
Source:
Probability Factor:
14.
Any other factors
which should be
taken into
consideration?
(e.g. Any other trigger
points?)
Monitoring and Review
Source:
Probability Factor:
Frequency
Date of next review
Name and status of person
Completing risk section of
this form.
Signature and Date
Name and Status of person
Completing Action section
Of this form.
Signature and Date
Elysian-Field Managers
Signature and Date
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