Placement Referral Form & Risk Assessment
Name:
Current Address:
CareFirst Number:
Legal Status:
DOB/EDD:
Ethnic Origin:
First Language:
Age:
Gender:
NOTE – If the request is for a parent and child placement please comment on the
needs/risks of parent and child separately on this form. Please be specific about who
the needs refer to.
Reason for Placement
Reason for placement:
Please provide a brief summary of events leading to the request including reasons for
previous placement breakdown if this is applicable:
What is the overall care plan for this child (e.g. reunification with family, adoption, foster care
until independence etc):
Requirements of Placement
Date Placement required:
Proposed length of placement:
Is the child required to move in within 48 hours?
What type of placement is required?
Select an Item
Please select from the drop down box
If you are seeking a respite placement please give specific details regarding the times and
frequency that respite care will be needed:
If the type of placement requested is not available by the required date please confirm what the
contingency arrangements will be for this child:
Geographical location required?
Ideal/acceptable/impossible
Can the child be placed in a placement with other children?
If there are conditions relating to this please provide as much detail as possible
Please detail any other essential criteria in selecting a placement for this particular child (e.g.
need to meet specific cultural needs, no pets in household, two carer household, rural location
etc):
What arrangements will be made for the child visiting, prior to the placement commencing?
Outcomes for young person
SMART Outcome
Timeframe to achieve/review
Health
Are there any significant health issues?
If the child is on medication please provide details including type of medication, how often it
is administered and the expectations of the carer(s) with regards to this or required specialist
training (and how this will be provided):
Provide details on any allergies and how these are managed:
Are there any issues relating to continence that carer(s) will need to be aware of, and if so
provide details?
Is a smoke free environment essential?
If the young person smokes how should this be managed by carers?
Give details of any mental health issues and details of any CAMHS involvement:
If therapeutic services are required in the placement please specify the type of therapy that is
to be provided and any other details of the requirements:
Disability if applicable
Please provide details of the child’s disability:
i.e. what is the nature of disability
Please provide details on access and mobility (in particular specify if there are any manual
handling issues):
Does the child need an adapted environment?
If yes, please give details:
Will the carer(s) require specific training and how will this be provided?
Offending Behaviour
Please provide details of any offending history:
Please detail if the child is on a curfew, tagged or on remand:
Has the child any history of fire starting behaviour, please give exact details of events and
dates (Failure to disclose any previous fire settings will invalidate some foster carers’
insurance policies):
Emotional & Behavioural
Has the child misused substances/alcohol in the past or currently?
If yes, please provide details:
Provide any relevant information on any absconding behaviour:
If the child self-harms provide specific details of this behaviour including frequency:
If the child has ever been a perpetrator of bullying provide as much detail as possible:
If the child exhibits any inappropriate sexual behaviour please provide as much detail as
possible:
If the child has been the victim or perpetrator of sexual abuse provide as much detail as
possible and including how the behaviour is best managed:
If the child has been the victim or perpetrator of physical abuse provide as much detail as
possible including how the behaviour is best managed:
If the child exhibits aggressive/violent behaviour provide as much detail as possible and
detail how the behaviour is best managed:
If the child has been subjected to emotional abuse/neglect provide as much details as
possible:
If the child has witnessed domestic violence provide as much detail as possible:
If the child presents a risk to pets or other animals provide specific details and detail how the
behaviour is best managed:
Individual Care Needs
Child’s morning routine that will need to be followed in the placement:
Child’s mealtime routine that will need to be followed in the placement:
Child’s bedtime routine that will need to be followed in the placement:
Child’s sleeping patterns and details of comfort aids:
Additional relevant information on the child’s personal care needs:
Child’s specific communication needs:
Further information the carer needs to know about the way the child presents themselves:
Details of possible issues if child shares a bedroom (please note that a specific risk
assessment must be completed if a child is to share a bedroom even if with a sibling):
Food likes, dislikes and allergies:
Child’s personal care needs (if a baby please include size of nappies & brand of milk formula
currently used):
Child’s current hobbies, special interests and leisure activities which will need to be
maintained in their placement:
Does the child need to learn any independent living skills, if so please provide details?
Please provide a short description of the child’s personality:
Education
Name & location of current/most recent school:
Is it important for the child to continue to attend this school?
If yes, how far could the child reasonably be expected to travel from their new placement to
their school and how should this be facilitated?
If the child is unable to continue at the above establishment due to geography of a new
placement, please specify what arrangements for education will be required:
Does the child currently attend school regularly?
Has the child been excluded or are they at risk of exclusion?
Does the child have a statement Special Educational Needs?
Does the child have a Personal Education Plan?
Description of child’s experience and attitude towards school:
Cultural & Religious Needs
Religion:
Is it important for the child to regularly attend a place of worship?
If yes, provide address, times of attendance and details of any other religious practices to be
observed:
If the child is unable to continue to attend their regular place of worship due to the geography
of a new placement, please provide any relevant information on the implications of this
change:
Contact Arrangements
Detail the required contact arrangements (frequency & location) and specifiy if there is
anyone with whom contact is prohibited or placement details withheld from:
Are there any friends that the child needs to maintain in contact with or should not maintain
contact with? Please give details:
Consultation
What are the child’s views and understanding with regard to this plan?
What are the parent’s/carers views with regard to this plan?
Info for Parent & Child Placements ONLY
Mother’s name / DOB
Father’s name / DOB
Baby’s equipment needs – who will need to
provide this?
Will the Local Authority be conducting a
parenting assessment?
If placing externally, do you require the
provider to conduct a parenting assessment?
What level of monitoring is required?
If placing externally, are any other services
required (i.e. cognitive assessment)?
Confirmation & Authorisation
Name, Team and telephone number of social
worker
Date
Name and telephone number of team manager
approving this form
Date
Name of Head of Service or EOC/Placement
Panel authorising this request
Date
For completion by Children’s Services Buyers
Date referral received
In-house referral no. allocated
External provider referral no. allocated (if
applicable)
Please complete the risk assessment below:
PSIP-
Type of Risk
Self Harm
Risk to other young people
within the household.
Risk to Carers
Risk to or from the
community
Education
House and Grounds
Outings and activities
Offending behaviour
Use of technology
1. Risks and Triggers
2. Avoidance measures
3. Measures to be taken
4. Indicate level of risk
Describe as fully as possible the actual
or potential risks presented to or from
the young person, indicate relevant
details of those young persons who are
or may be at risk, and what the warning
signs or triggers are.
Describe measures needed to reduce
risk. Include details of any restrictions
such as TV/electrical items, access to
sharp objects, level of staff supervision
required. Phrases or tone of voice to
use. Location best suited to dealing with
incident. Consider specific bail condition
if appropriate.
Describe measures needed to address
risk. Include details of what action
should be taken, when it should be taken
and where. Include information on
phrases/voice tone, appropriate touch,
actions and rewards.
H = High (recent and frequent
occurrence of behaviour)
M=Medium (recent but infrequent
occurrence of behaviour)
L=Low (historical, 3 months prior and
infrequent occurrence of behaviour)
(computers/mobile phones)