Business Information & Support Officer



Access to Resources Children’s Team

REFERRAL FORM

REFERRAL TO THE ACCESS TO RESOURCES PANEL / CHILDREN IN CARE PANEL / REQUEST FOR PLACEMENT

The core information in Section 1, Parts 1 – 4 must be completed for ALL referrals

Please indicate type of referral by selecting one of the boxes below.

Please complete the relevant parts as stated below

| |Section 1 |Complete Parts |

|[pic] |Placement Request for In-House Fostering |1, 2, 3, 4, 5, 7, 8, 9, 12 |

|[pic] |Request for Parent & Child (information required regarding Parent & Child) |1, 2, 3, 4, 5, 6, 7, 8, 9,10,11,12 (If external 17) |

|[pic] |Request for External Independent Fostering |1, 2, 3, 4, 5, 6, 7, 8, 9,12, 17 |

|[pic] |Request for External Residential |1, 2, 3, 4, 5, 7, 8, 9, 12, 17 |

| |Section 2 |Complete Parts |

|[pic] |Access to Resources Panel |1, 2, 3, 4, 5,15 |

|[pic] |Children in Care Placement Panel |1, 2, 3, 4, 5,16 |

| |Section 3 |Complete Parts |

|[pic] | |17 |

| |Authorisation from SCS Assistant Director for IFP or Residential Placement | |

Please email to: ARTChildrens@.uk

General enquiries: 0300 333 6331

Section 1

|Contract reference |      |

|(only to be completed by ART) | |

Part 1 – Referrer Details

|Name of Referrer | | | |

|(if not allocated Social Worker) | | | |

| |Area |District |Team |

|      |      |      |      |

|Name of allocated Social Worker(s) | | | |

| |Telephone number |Mobile number |Email address |

|      |      |      |      |

|      |      |      |      |

|Name of Team Manager |Telephone number |Mobile number |Email address |

|      |      |      |      |

Part 2 – Child’s Details

|ICS ID |Name |Date of Birth |Age |Gender |

|      |      |      |      | |

|Ethnicity | |

|If other, please give details |      |

|Religion | |

|If other, please give details |      |

|Practising | |

|Main Language | |

|If other, please give details |      |

|      |

Does the child have a disability?

(Outline nature of disability)

|Home address |      |

|Child’s Status / Legal Status |Date of Child in Need Plan |Date of Child Protection Plan |

| |      |      |

| | | |

|Category of Child Protection |Date of current core assessment/single |Is the child subject to PLO proceedings? |

| |assessment | |

|      |      | |

|Current Placement | |

|If other, please give details |      |

| | |Must remain at current school |

|Statement of SEN |Date of SEN | |

| |      | |

| | | |Year Group |

|Education Setting |Name of School |Address of School | |

|      |      |      |      |

Part 3 – Family Composition

|Name of Persons’ with parental responsibility |      |

| | |Is there a requirement to place any | |

| | |of the siblings with this child | |

|Name |Relationship | |Address |

|      |      | |      |

|      |      | |      |

|      |      | |      |

|      |      | |      |

|      |      | |      |

|      |      | |      |

If yes, you will be required to complete a referral form for each child.

Part 4 – Child’s Assessed Needs

| | | |

| | |What is the current Care Plan, also state if |

| |Describe immediate issues/difficulties/strengths)|parents are in agreement with Care Plan? |

|Childs primary needs | | |

| |      |      |

| | |

| | |

|What are the child/young person’s wishes and feelings and are they in |What other agencies are involved and how are they contributing to the |

|agreement with the plan? |plan? |

|      |      |

|Placement history (include any breakdowns and disruptions in foster | |

|care/residential/with extended family members) | |

| |Brief Intervention history of what has been tried |

|      |      |

| | |

| |Details including reasons for ending of previous care episodes (names of |

|Has there been previous care episodes |previous carers and dates of care episodes must be included) |

| |      |

| | |

|Has there been more than 3 previous placement moves within the last 18 |Details including reasons for ending of previous placements |

|months | |

| |      |

|Are there any equality and diversity issues and how have they been |What are the child/young person’s current and future educational needs |

|addressed e.g. specific diet, mobility, communication methods (sign |e.g. do they have a management plan, is the child receiving full time |

|language, PECS) etc? |education, excluded etc? |

|      |      |

|What are the child/young person’s current and future health needs e.g. do |      |

|they have a diagnosis, allergies, medication, conditions etc? | |

|Does the child receive any therapy or any other medical intervention? If |      |

|yes, please give details | |

|Are there any specific behavioural and emotional problems which prospective foster carers need to be aware of e.g. has a child/young person been |

|sexually abused, aggression towards adults/children? |

|      |

| |

| |

|Give a brief description of the child, including strengths, attributes, likes, dislikes, activities and interests |

|      |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|BACKGROUND |

|(Details of home/family situation) |

|      |

| |

| |

Part 5 – Placement Requirements

Agreement for child/young person to be placed in care

| | |Signature | | |

|Service Manager | | | | |

| | | | |Date |

|      | | | |      |

|Date of request for placement/service |Date placement/service required |

|      |      |

|Reason for placement being requested |Anticipated length of placement |

|      |      |

|Type of placement | |

|Describe any specific skills required by the foster carers |      |

|Outline any specific equipment requirements, e.g. hoist, ramps etc |      |

Select categories in boxes below

|Category |Category |

| | |

Part 6 – Placement Category (IFP Placements only)

|Select one of the following (If Parent and Child or Residential Migration, this will be “Specialist”) |

|[pic] |Standard |

| |(The child/young person requires consistent boundaries and a highly managed structured environment) |

|[pic] |Complex |

| |(The child/young person requires enhanced risk management or intensive management approaches) |

|[pic] |Specialist |

| |(The child/young person requires additional specialist support in relation to multiple and profound disabilities, complex medical needs,|

| |profound mental health difficulties) |

Part 7– Matching Details

|Does this child need to be the youngest/oldest/same gender? |      |

|Has the child experienced loss or change of primary carer in the first 5 |      |

|years of life? If yes, please give details | |

|Do the parents/family members pose any risks that the Foster |      |

|Carer/Residential Unit should be aware of? | |

Part 8 – Matching Requirements

|Requirements: |If Required: |Any additional information: |

|Placement in specific location (state location and reason) | |      |

|Placement with no other children/solo placement | |      |

|Placement with no younger children | |      |

|Placement with no older children | |      |

|Placement with siblings, can share bedroom | |      |

|Placement with siblings, but not sharing bedroom | |      |

|Placement in an emergency | |      |

|Bridge to Adoption placement | |      |

|Remand placement | |      |

|Short Term placement | |      |

|Placement with no pets | |      |

|Carers/Residential Unit with experience of disabilities | |      |

|Carers/Residential Unit with experience of children who have been | |      |

|sexually abused | | |

|Carers/Residential Unit with experience with working with children who| |      |

|have experienced sexual exploitation or trafficking | | |

|Contact frequency requirement (state) | |      |

|Contact requirement location (state) | |      |

|Contact travelling requirement (state) | |      |

|Contact supervision requirement (state) | |      |

|Carers/Residential Unit with experience of working with unaccompanied | |      |

|asylum seeking children | | |

|Carers/Residential Unit who have experience of meeting the needs of | |      |

|children with different cultural, religious and linguistic needs | | |

Part 9 - Outcomes

|Identify what outcomes should be achieved whilst the child is in placement|      |

|e.g. rehabilitation home within 3 months, requires foster carer to work | |

|with all parties to get child/young person home | |

Part 10 – Parent & Child Placement

|Name of parent(s) who will be in placement | | | |

|with child | | | |

| |Gender |Date of Birth |Ethnicity |

|      | |      | |

|      | |      | |

| | |

|Parent(s) home address |Name of persons’ with parental responsibility for parent if child in care |

|      |      |

|      |      |

|Please outline reason for placement, include why they are unable to remain|      |

|at home | |

|Purpose of placement request e.g. parenting capacity assessment |      |

|Agreed duration of placement |      |

|Are any other assessments being undertaken? Please give details e.g. |      |

|psychological assessment ordered by court | |

|Is the parent(s) a child in care or a care leaver? If yes, please give |      |

|details | |

|Describe any specific tasks required of the foster carer e.g. 24 hour |      |

|supervision, other child care tasks | |

|Has either parent experienced significant loss or recent relationship |      |

|breakdown? If yes, please give details | |

|Give a brief outline of the parent(s) needs, strengths and attributes |      |

|Outline any specific physical, religious, cultural, diet, mobility, |      |

|learning disability needs of parent(s) | |

|Do the parents/family members pose any risks that the Foster Carer should |      |

|be aware of? | |

|Is the parent(s) receiving full time education, training or on any other |      |

|programme? If yes, please give details | |

|Name of parent(s) school? (If applicable) |      |

|If excluded, please give reasons and time period? (if applicable) |      |

|Does either parent(s) require or receive any form of therapy or on-going |      |

|treatment for mental health e.g. addictions? If yes, please give details | |

|Financial situation of parent(s) what benefits do they receive? |      |

|Are the parent(s) in agreement with the care plan and proposed placement |      |

|arrangements? | |

|Additional comments |      |

Part 11 - Matching requirements for parents

Requirements If Required Any additional information

|Placement in specific location (state location and reason) | |      |

|Placement of child and parent(s) as only placement | |      |

|Carers who have experience of meeting the needs of children with | |      |

|different cultural, religious and linguistic needs | | |

|Placement with no pets | |      |

|Carers with experience of disabilities/learning disabilities | |      |

|Carers with experience of children who have been sexually abused | |      |

|Carers with experience with working with children who have experienced| |      |

|sexual exploitation or trafficking | | |

|Outline any contact arrangements with any family members |      |

Please complete the Risk Assessment Form (Part 12).

Part 12a – Risk Assessment

IDENTIFIED RISKS

|Risk: |Current: |Previous History: |Indicate Level of Risk |Brief Details (if applicable): |

| | | |(High, Medium, Low): | |

|Aggression/violence towards others | | | |      |

|Criminal/offending behaviour | | | |      |

|Any admissions to: | | | |      |

|Special Hospital | | | | |

|Y.O.I. (Young Offenders Institution) | | | | |

|Psychiatric Hospital | | | | |

|Preoccupation/ obsession with weapons | | | |      |

|Threats to harm others | | | |      |

|Bullying | | | |      |

|Sexual abusive behaviour to others / risk | | | |      |

|to other children | | | | |

|Vulnerability to sexual exploitation | | | |      |

|Self harming behaviour | | | |      |

|Arson / fire setting | | | |      |

|Problems with alcohol or substance misuse | | | |      |

|An expression of concern from others about| | | |      |

|the risk of violence | | | | |

|Racial abuse / discriminatory behaviour | | | |      |

|Allegations against staff / carers | | | |      |

|Threatening behaviour in the community | | | |      |

|Absconding behaviour | | | |      |

|Other | | | |      |

|Are there any active factors that indicate an increased risk to others? | |

Part 12b - OTHER AGENCIES / WORKERS INVOLVED

| |

|Give details of involvement |

|      |

| |

| |

|What is the child’s/young person’s view of their behaviour? |

|      |

| |

| |

|In your professional judgement, is a detailed assessment of risk required? | |

If Yes complete DETAILED RISK ASSESSMENT (Part 12c).

Part 12c - DETAILED RISK ASSESSMENT

If more than one risk is evident complete for each risk

Areas of Risk

|Describe risk event or incident e.g. Where did it occur? Who suffered |      |

|harm? Nature of any injuries/abuse? | |

|Approximate date e.g. recent or past event history |      |

|Information sources for incident |      |

|Context of event |      |

|Any known precipitants e.g. motivation, stressors? (include client & | |

|others’ view) | |

|Known triggers |      |

|Warning signs and/or settings that trigger risk and time of highest | |

|risk/patterns of behaviour | |

|Outcome of event |      |

|What measures / types of intervention are to be put in place to reduce | |

|risk and their effectiveness from client & other’s viewpoint? (See Risk | |

|Management Plan) | |

|What is the likelihood of reoccurrence? |      |

Risk Assessment completed by

|Name of Social Worker | |Social Worker’s Signature | |Date |

|      | | | |      |

|Part – 12d RISK MANAGEMENT PLAN | |

|Management Plan |

| |

|Consider: |

| |

|Nature and degree of risks identified; who is at risk? How likely is it to occur? |

| |

|Relationship between risk, current social circumstances or other contextual factors |

| |

|Factors increasing the risk and protective factors that reduce risk. Previous helpful interventions |

| |

|Client’s, carers’ and others’ views of risk |

| |

|Gaps in information. |

| |

| |

|Guidance for written Plan |

| |

|Location of interviews with child/family/carer |

|Number and status of staff to be present |

|Reporting back mechanisms |

|Who else needs to know about this risk management plan e.g. colleagues, in other parts of department / council / other agencies / carers? |

| |

|Be specific – who, what, when, where and MUST NOTS. |

|      |

| |

| |

| |

| |

| |

Risk Management Plans must be reviewed every three months or after any significant incident, whichever is the sooner.

|Risk Assessment review date |

|      |

|Completed by Social Worker | |Date |

| | |      |

|Authorised by Team Manager | |Date |

|      | |      |

Part 13 – Placement Offer (ART Officer to complete in conjunction with the Social Worker when placement offered)

|Have the Social Workers for the children currently in placement been |      |

|consulted? | |

In-House Fostering Placement

|Name of Foster Carer |      |

|Address of Foster Carer |      |

|Area in which Foster Carer lives | |

|Name of Supervising Social Worker for Foster Carers |      |

IFP Placement

|Name of IFP Provider |      |

|Address of IFP Provider |      |

|Name of Foster Carer |      |

|Address of Foster Carer |      |

|Area in which Foster Carer lives | |

|Name of Supervising Social Worker for Foster Carers |      |

Residential Placement

|Name of Residential Provider Organisation e.g. Head Office |      |

|Address of Residential Provider Organisation |      |

|Name of Residential Unit |      |

|Address of Residential Unit |      |

|Area of Residential Unit | |

Placement Details

|What is the weekly cost of the placement? |£      |

|Weekly costs of any additional services provided? |£      |

|Start date of placement |      |

|Review date |      |

|End date |      |

Part 14 – Matching Requirements Met

|Requirements |Please indicate which requirements have been met by the placement offer |

| |and any additional comments |

|Placement in specific location (state location and reason) | |      |

|Placement with no other children | |      |

|Placement with no younger children | |      |

|Placement with no older children | |      |

|Placement with siblings, can share bedroom | |      |

|Placement with siblings, but not sharing bedroom | |      |

|Placement of child and parent(s) together | |      |

|Placement of child and parent(s) as only placement | |      |

|Placement in an emergency | |      |

|Bridge to Adoption placement | |      |

|Remand placement | |      |

|Short Term placement e.g. care proceedings | |      |

|Placement with no pets | |      |

|Carers with experience of disabilities | |      |

|Carers with experience of children who have been sexually abused | |      |

|Carers with experience with working with children who have experienced sexual| |      |

|exploitation or trafficking | | |

|Contact frequency requirement (state) | |      |

|Contact requirement location (state) | |      |

|Contact travelling requirement (state) | |      |

|Contact supervision requirement (state) | |      |

|Carers with experience of working with unaccompanied asylum seeking children | |      |

|Carers who have experience of meeting the needs of children with different | |      |

|cultural, religious and linguistic needs | | |

Please ensure that this section is completed in conjunction with the Social Worker to identify what matching requirements have been met.

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