croydon early help assessment form

1

Ethnicity

WhiteBritish WhiteIrish

AnyotherWhitebackground

TravellerofIrishHeritage Gypsy/Roma

White/BlackCaribbean White/BlackAfrican

White/Asian

Anyothermixedbackground

Indian Pakistani

Bangladeshi

AnyotherAsianbackground

Caribbean African

AnyotherBlackbackground

Chinese Anyotherethnicgroup

Prefernottosay Informationnotyetobtained

Gender

Male Female Unborn

Is an interpreter required? Language

Yes No

Child(ren)/Young Person(s)’s details

Contact Details (Telephonenumber,mobile,email)

UPN

School/College/Nursery

Last Name First Name Also known as

Age DOB/EDD(--/--/-----) Address Postcode

CROYDON EARLY HELP ASSESSMENT FORM

Category of agency

Education(4yearsandover) SocialCare Health MentalHealth Earlyyears

Housing FamilySupport Police/Probation VoluntaryOrganisation

Assessor’s Details

Name of Assessor

Job role

Organisation

Address

Telephone number

Postcode

Email

Disability/SEN Isdisabled Isondisabilityregister AnySENneeds Pleasespecify

Date assessment started

2

Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Gender

Male Female Unborn

Gender

Male Female Unborn




UPN



UPN









Yes No


Yes No

3

Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Gender

Male Female Unborn

Gender

Male Female Unborn




UPN



UPN









Yes No


Yes No

4

Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Gender

Male Female Unborn

Gender

Male Female Unborn




UPN



UPN









Yes No


Yes No

5

Type of responsibility

Maincarer Nextofkin

Emergencycontact Parentalresponsibility

Type of responsibility

Maincarer Nextofkin

Emergencycontact Parentalresponsibility

Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Gender

Male Female

Gender

Male Female

Parent / Carer details

Parent / Carer details





Age DOB(--/--/-----) Address Postcode





Yes No


Yes No

6

Relationship to child(ren)/Young person


Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Gender

Male Female

Gender

Male Female


Yes No


Yes No

Other significant people










7



Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Ethnicity





White/Asian


Indian Pakistani

Bangladeshi


Caribbean African




Gender

Male Female

Gender

Male Female


Yes No


Yes No











8

Professionals / Key Agencies involved

Last Name

Organisation

Email

First Name

Names of family members currently receiving support

Involvement start date

Job Role

Telephone number


Last Name

Organisation

Email

First Name



Job Role

Telephone number


Last Name

Organisation

Email

First Name



Job Role

Telephone number

9


Last Name

Organisation

Email

First Name



Job Role

Telephone number


Last Name

Organisation

Email

First Name



Job Role

Telephone number


Last Name

Organisation

Email

First Name



Job Role

Telephone number

Primary reason for assessment

Health Emotional,Social&Behavioural Identity,Independence,Relationships&SocialPresentation

Learning&Participation Parents&Carers Family&Environment Housing,Employment&Finance

10

What has led to this assessment?

11

Parent / Carer’s comments

Child / Young Person’s comments

Health – general health; physical development

How well on a scale of 1-6 is the family doing in this area? *Required(1–notwell;6–verywell) 1 2 3 4 5 6

Development of the unborn baby, infant, child or young person

12



Emotional, Social & Behavioural – emotional and social development; behavioural development


13



Identity, Independence, Relationships & Social Presentation - Identity, self-esteem, self-image and social presentation, family and social relationships, self-care and independence


14



Learning & Participation – understanding, reasoning and problem solving, participation in learning, education, and employment, progress and achievement, aspirations, speech, language and communication


15



Basic care, ensuring safety and protection; emotional warmth and stability; guidance, boundaries and stimulation


Parents & Carers

16



Family & Environment – family history, functioning and wellbeing, wider family, social and community elements


Family, Environment & Finance

17



Housing, Employment & Finance – housing, employment and financial considerations


18

What needs to change? How will we know when it has been achieved?

What needs to change?

19

Consent Details

Please submit securely to [email protected]

Please provide feedback about the use of this form via the survey monkey link www.surveymonkey.com/s/zb2bxyq

Guidance for this form is available at www.practitionerspacecroydon.co.uk/support-assessment/is-it-for-me-caf

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:

Yes No

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

Yes No Parent / Carer Signature Date

The young person gives their consent

Yes No Young Person Signature Date

150355

Date assessment completed

croydon early help assessment form

Documents