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Early Help Assessment
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the form will then be submitted to the Early Help Hub.

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Child/Family Details
Identifying Details - Details of children and young people in the family
Record details of unborn baby, infant, child, young person being assessed. If unborn, state name as 'unborn baby' and mother's name, e.g. unborn baby of Ann Smith.
District
*
Identifying Details - Details of children and young people in the family
Name
Date of Birth or Estimated Delivery
 
Gender
Ethnicity
Address

Details of Parents/carers/household members
Person Name
Relationship to child
Contact Number
Address
Parental Responsibility?

Additional Information
Immigration Status
Child's First Language
Parents's First Language
Disability
If yes, give details
Details of any special requirements (for child and/or their parent) e.g. signing, interpretation or access needs

Current Family & Home Situation - e.g. family structure including siblings, other significant adults etc. who lives with the child and who does not live with the child
Why has this family assessment been started?
Relationship Difficulties At Home
Relationship Difficulties At School
Behaviour: home/community
Behaviour: school
Attendance at educational setting
Drug/alcohol issues (young person)
Drug/alcohol issues (parent/carer)
Not in education, employment or training
Parental disability
Risk Taking Behaviour
NEET prevention (Red/Amber RONI)
Domestic abuse
Exclusion from educational setting
Parenting
Child's development/learning
Housing/Economical issues
Mental health
Concerns regarding emotional wellbeing (child/young person)
Teenage pregnancy
Child/YP disability
Low Level/Emerging Neglect

What has led to this child/young person & family being assessed?
On a scale of 1-5 (1 =low and 5 = significant) please give REFERRER score on the impact on the parent/carer in terms of the referral issues stated above:
*
On a scale of 1-5 (1 =low and 5 = significant) Please give REFERRER score on the impact on the child/young person in terms of the referral issues stated above:
*
Single or Multi-Agency Assessment
*
Details of Person(s) Undertaking Assessment & Lead Professional
Name
Contact No
Role
Organisation
Address
Postcode

Lead Professional
Involved in assessment

Services Working with this Infant, Child or Young Person:
Name
Organisation
Telephone No
E-mail Address
Address
Working with

Consider each of the elements to the extent they are appropriate in the circumstances.
You do not need to comment on every element. Wherever possible, base comments on evidence, not just opinion, and indicate what your evidence is. However, if there are any major differences of view, these should be recorded too.
Complete for all children, young people in the family where there are additional needs/concerns.
Development of unborn baby, infant, child or young person - Consider General Health, Physical Development, Speech, Language & Communication, Emotional and Social Development, Behavioural Development, Identity, self-esteem, self-image & social presentation, Family & social relationships, Self-care skills and independence, Learning- Understanding, Reasoning and Problem Solving, Participation in Learning Education and Employment, Progress and achievement in learning, Aspirations
Parents and Carers - Consider Basic Care, ensuring safety and protection, Emotional Warmth and stability, Guidance, boundaries and stimulation
Family and Environmental - Consider Family History, functioning and well-being, Wider family, Housing, employment and financial considerations, Social and community elements and resources, including education
Conclusions, Solutions and Actions
Now the assessment is completed, you need to record conclusions, solutions and actions. Work with the child or young person and/or parent or carer, and take account of their ideas, solutions and goals. Consider the child's/young person's/family's strengths and resources.
Analysis
'Goals (e.g. How will you know that things have improved? What will things look like at review from practitioner, child, young person and family perspective?)
What are the next steps?
In order of priority list the actions agreed for the people present at the assessment
Action Plan
Issue
Action Plan
Who will do this?
By When?
 

Is a multi agency meeting needed?
*
If yes, agreed review date
 
If no date agreed, by when should this meeting have taken place?
 
Assessment initiated by
*
Role
Organisation

If other has been specified for Role or Organisation please give details
Is this a Step Down?
*
Family Comments
Child/Young Persons comments (on the assessment and actions identified)
What score would you give the main issue NOW:
Parent or carer's comments (on the assessment and actions identified)
What score would you give the main issue NOW:
Consent
We need to collect the information in this 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 other organisations, so that they can help us to provide the services you need. 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.
Please name any agencies who you DO NOT wish information to be shared with:
I have had the reasons for information sharing explained to me and I understand those reasons.
Please verify that this form has been seen & agreed by the child/young person or parent/carer.

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Date Completed

If you require any support in completing this form please contact your Integrated Working Coordinator.