CROYDON EARLY HELP ASSESSMENT FORM
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1 CROYDON EARLY HELP ASSESSMENT FORM Date assessment started Assessor s Details Name of Assessor Address Postcode Job role Telephone number Organisation Category of agency Education (4 years and over) Social Care Health Mental Health Early years Housing Family Support Police/Probation Voluntary Organisation Child(ren)/Young Person(s) s details Age DOB/EDD (--/--/-----) Address Postcode Male Female Unborn UPN School/College/Nursery 1
2 Child(ren)/Young Person(s) s details Age DOB/EDD (--/--/-----) Address Postcode Male Female Unborn UPN School/College/Nursery Child(ren)/Young Person(s) s details Age DOB/EDD (--/--/-----) Address Postcode Male Female Unborn UPN School/College/Nursery 2
3 Child(ren)/Young Person(s) s details Age DOB/EDD (--/--/-----) Address Postcode Male Female Unborn UPN School/College/Nursery Child(ren)/Young Person(s) s details Age DOB/EDD (--/--/-----) Address Postcode Male Female Unborn UPN School/College/Nursery 3
4 Parent / Carer details Age DOB (--/--/-----) Address Postcode Male Type of responsibility Main carer Emergency contact Male Type of responsibility Main carer Emergency contact Female Female Next of kin Parental responsibility Parent / Carer details Age DOB (--/--/-----) Address Postcode Next of kin Parental responsibility 4
5 Other significant people Age DOB (--/--/-----) Address Postcode Male Relationship to child(ren)/young person Male Female Female Relationship to child(ren)/young person Other significant people Age DOB (--/--/-----) Address Postcode 5
6 Other significant people Age DOB (--/--/-----) Address Postcode Male Relationship to child(ren)/young person Male Female Female Relationship to child(ren)/young person Other significant people Age DOB (--/--/-----) Address Postcode 6
7 Professionals / Key Agencies involved Last Name First Name Job Role Organisation Names of family members currently receiving support Telephone number Involvement start date Professionals / Key Agencies involved Last Name First Name Job Role Organisation Names of family members currently receiving support Telephone number Involvement start date Professionals / Key Agencies involved Last Name First Name Job Role Organisation Names of family members currently receiving support Telephone number Involvement start date 7
8 Professionals / Key Agencies involved Last Name First Name Job Role Organisation Names of family members currently receiving support Telephone number Involvement start date Professionals / Key Agencies involved Last Name First Name Job Role Organisation Names of family members currently receiving support Telephone number Involvement start date Professionals / Key Agencies involved Last Name First Name Job Role Organisation Names of family members currently receiving support Telephone number Involvement start date Primary reason for assessment Health Emotional, Social & Behavioural Identity, Independence, Relationships & Social Presentation Learning & Participation Parents & Carers Family & Environment Housing, Employment & Finance 8
9 What has led to this assessment? Development of the unborn baby, infant, child or young person Health general health; physical development How well on a scale of 1-6 is the family doing in this area? *Required (1 not well; 6 very well) Parent / Carer s comments Child / Young Person s comments 9
10 Emotional, Social & Behavioural emotional and social development; behavioural development How well on a scale of 1-6 is the family doing in this area? *Required (1 not well; 6 very well) Parent / Carer s comments Child / Young Person s comments Identity, Independence, Relationships & Social Presentation - Identity, self-esteem, self-image and social presentation, family and social relationships, self-care and independence How well on a scale of 1-6 is the family doing in this area? *Required (1 not well; 6 very well) Parent / Carer s comments Child / Young Person s comments 10
11 Learning & Participation understanding, reasoning and problem solving, participation in learning, education, and employment, progress and achievement, aspirations, speech, language and communication How well on a scale of 1-6 is the family doing in this area? *Required (1 not well; 6 very well) Parent / Carer s comments Child / Young Person s comments Parents & Carers Basic care, ensuring safety and protection; emotional warmth and stability; guidance, boundaries and stimulation How well on a scale of 1-6 is the family doing in this area? *Required (1 not well; 6 very well) Parent / Carer s comments Child / Young Person s comments 11
12 Family, Environment & Finance Family & Environment family history, functioning and wellbeing, wider family, social and community elements How well on a scale of 1-6 is the family doing in this area? *Required (1 not well; 6 very well) Parent / Carer s comments Child / Young Person s comments Housing, Employment & Finance housing, employment and financial considerations How well on a scale of 1-6 is the family doing in this area? *Required (1 not well; 6 very well) Parent / Carer s comments Child / Young Person s comments 12
13 What needs to change? What needs to change? How will we know when it has been achieved? 13
14 Consent Details Consent Statement & Approach Consent statement for information storage and information sharing We need to collect the information in this EHA form so that we can understand what help you may need. If we cannot cover all of your needs we may need to share some of this information with the other organisations, so that they can help us to provide the services you need. We will treat your information as confidential and we will not share it with any other organisation unless we are required by law to share it or unless you or any other person will come to some harm if we do not share it. In any case we will only ever share the minimum information we need to share. Anonymised data from your record may also be used to help us monitor and improve services in the future. I understand the information that is recorded on this form and that it will be stored and used for the purpose of providing services to: Me This infant, child or young person for whom I am a parent This infant, child or young person for whom I am a carer I have had the reasons for information sharing and information storage explained to me and I understand those reasons: I agree to the sharing of information, as agreed, between the services areas listed below. Please tick all the areas you are happy to share information with. Education Social Care Health Mental Health Housing Family Support Police/Probation Voluntary Organisation The parent(s) / carer(s) give their consent Parent / Carer Signature Date The young person gives their consent Young Person Signature Date Date assessment completed Please submit securely to childreferrals@croydon.gov.uk Please provide feedback about the use of this form via the survey monkey link Guidance for this form is available at 14
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