Southampton Universal Partnership Plus Assessment Tool
For unborn babies and pre-school aged children and their parents or carers requiring early intervention at Universal Plus or
Universal Partnership Plus through Children’s Centre Partnerships.
Date form completed
Name of Completer
Parent and child registration with Sure Start
confirmed:
Completer Contact Details
Identifying details (for unborn baby, infant, child or young parent under 18)
Name of child or
young parent
Name of Mother
Date of Birth of
child/young parent
Name of Father
Baby due date
Contact tel.no of
Parents/Carers
NHS number if
known
Gender
M
F
Child or young
parent’s first
language
Address
(where the child
or young parent is
living)
Parent/carer’s first
language
Section A (must be completed) Tick and describe any concerns about the baby, child, young person or
parents:
(Record observations and comments from the parent, child or young person and the completer.)
Child development and school readiness
 Personal, social and emotional development
Physical development
Parenting aspirations, self esteem and parenting skills
Parent/child relationship
Appropriate expectations of child
Parenting skills
Communication and language
Parent’s confidence and self esteem
Child and family health and life chances
Child’s physical health
Child’s mental health
Parent’s physical health
Parent’s mental health
Young parent
Safety
Social isolation
Training and skills
Housing and environment
Money
Who is in the child, young person or parents’ support network? How do they help?
Partner, family or friends
Health visitor:
Midwife:
Early Years practitioner:
Other workers:
Has anyone else recently assessed this family?
Are there other children in the family?
Yes
No
If yes, are there additional needs for any of these children?
Yes
Yes
No
No
Details of other children who have additional needs:
First name
Last name (if different)
Date of birth
What type of assessment
was done?
When?
Nursery
or school
Section B
What do you consider to be the primary need?
What support would you suggest?
This information will be shared with the other agencies who will be involved in supporting the parent or child,
please ensure it is understood and signed by the parent/carer. In certain circumstances this can be the young
person themselves.
All data will be kept according to the Data Protection Act 1998. Information recorded on this form will be used to support
decisions about appropriate service support. This may include practitioners from various services in a multi agency
meeting. It will also be shared with those who provide the support for the parent or child.
By ticking the box, I confirm that the completer has explained to me how the information in this form will be used.
Name of completer
Agency/Service
Name of parent/carer or young person
Signature of completer
Signature of parent/carer or young person
This completed form should be given to the SUPPAT meeting administrator at the local Sure Start Children’s Centre.
For completion at the SUPPAT meeting or with manager
Date:
Can the Children’s Centre and partners provide the additional support needed?
Yes – action plan agreed and review date set.
No - complete an Integrated Assessment of
Need
Tier 3 Service Referral needed immediately
To be completed by:
Date actioned:
To be referred by:
Date actioned: