Placement Referral Information - Bryn Web viewLac or DOH Documents (inc Care Plan) Yes; N/A; Core...

Document Ref No: YP/A/14/02j

Placement Referral Information[Type the document subtitle]

Name of Young Person:

Placing LA:

Improving the quality of life for young people with complex needs

ContentsPlacement Form....................................................................................................................................2

1.0 Essential Information about the Young Person..........................................................................2

2.0 Legal Status................................................................................................................................2

3.0 Placement History......................................................................................................................3

4.0 Family Information....................................................................................................................3

4.1 History.......................................................................................................................................3

4.2 Birth Parents..............................................................................................................................3

4.3 Significant Other........................................................................................................................4

4.4 Siblings.......................................................................................................................................4

4.5 Contact Arrangements...............................................................................................................4

5.0 Medical History..........................................................................................................................5

6.0 Safety Concerns.........................................................................................................................5

7.0 Offending Behaviour..................................................................................................................6

8.0 Current Presentation.................................................................................................................6

9.0 Please outline the Young Persons Protective Factors................................................................7

10 Educational Status.....................................................................................................................7

11 Placement Expectations.............................................................................................................9

12 Placement Aims and Objectives...............................................................................................10

13 Agency Contact Details............................................................................................................10

14 Social Worker...........................................................................................................................10

15 Other Significant Professional’s Details...................................................................................10

16 Referrer’s Details.....................................................................................................................11

17 Referral Documentation Provided...........................................................................................11

18 Funding- Authority Details.......................................................................................................11

19 Any Additional Information.....................................................................................................12

20 Pre-Admission Checklist...........................................................................................................13

YP – ADMISSIONS DOC REF NO: YP/A/14/02J

Placement Form

Please complete all sections as comprehensively as possible. In the event of an agreed placement, the information will be shared with the Young Person referred.

The information will be used as follows:

To assess whether a suitability of placement identified To develop an individual placement plan for the Young person referred with

supporting risk assessments To enable all read of our service to work therapeutically and successfully with the

Young Person, addressing issues you have identified and greed in consultation with the Young Person and any significant others.

FAILURE TO SHARE INFORMATION KNOWN COULD JEOPARDISE THE SAFETY AND WELL-BEING OF THIS YOUNG PERSON AND THOSE RESPONSIBLE FOR THEIR CARE.

1.0 Essential Information about the Young Person Full Name: Date of Birth:

Gender: Height:

Weight/Build: Telephone:

First Language: Ethnic Origin:

Religion (practicing/non) please specify any supporting religious or cultural needs:

Current Placement:

Current Address& Postcode:

Date Placement Required:

2.0 Legal Status

Current Legal Status:

Date Entered Care System:

Original Reason for Accommodation:


3.0 Placement HistoryType of Placement Number Of Placements Dates

Family Moves

Foster Placements

Residential Placements

Secure Placements

Hospital Placements

Other

4.0 Family Information

4.1 HistoryHistory

.

4.2 Birth Parents Mother’s Name: Telephone No:

Current Address:

Father’s Name: Telephone No:

Current Address:


Notes

.

4.3 Significant Other Name: Telephone No:

Current Address:

Name: Telephone No:

Current Address:

4.4 SiblingsName Age:

Address:

Name: Age:

Address:

Name: Age:

Address:

4.5 Contact Arrangements Current Level of contact between Young Person and family/significant persons

.


Any Restricted Contact

.

5.0 Medical History Does the Young Person have any specific health conditions or on-going health needs?

.

Is the Young Person prescribed any Medication?

.

Does the Young Person have any known allergies?

.

Has the Young Person been assessed by a psychiatrist or psychologist? Please outline any conclusions

.

Current GP Contact Details

.

6.0 Safety Concerns Does the Young Person have a history of any of the following problems? Please add your comments (including details of frequency of problem, and current state of the difficulty)


Problem Comments

Fire Setting?

Sexual Exploitation or prostitution?

Absenting or running away?

Aggressive or violent behaviour?

Self-Harm

Alcohol, drug, or substance misuse?

Predatory sexual behaviour?

Is the Young Person a schedule one offender?

Is the Young Person subject to MAPPA status? If so please outline the status and restrictions?

Other (please state)

7.0 Offending Behaviour Last Offence

.

Previous Convictions

.


Is the Young Person currently subject to any court order/YJS interventions

.

Contact details for YJS

.

Outstanding Court dates

.

Any bail/remand conditions

.

8.0 Current Presentation Current attitude/level of esteem

.

Likely effect on peer group

.

Likely attitude towards staff, male/female

.


Ability to adapt to new situations

.

Ability to communicate (verbally or otherwise)

.

Interests/hobbies

.

Willingness to participate in structured individual programme.

.

9.0 Please outline the Young Persons Protective Factors

.


10 Educational StatusPrevious Education Placements

.

Current/Previous attendance

.

Unique Pupil Number (UPN)

.

Date of last PEP review

.

Statement of Special Educational Needs

.

Last Date of Annual Statement Review

.


Any Learning Difficulties/Disabilities

.

Key Stage

.

Current Year Group

.

National Curriculum Level

.

Strengths and Achievements

.


11 Placement Expectations In what way can this placement help the Young Person to develop?

.

How do you think the Young Person will respond to this placement?

.

Has the Young person a current Pathway Plan?

.

What is the current long-term plan for this Young Person?

.

Has the Young Person an independent visitor or advocate?

.

What are the specific areas & behaviours you would like us to address?

.


What are the specific areas & behaviours you would like us to address?

12 Placement Aims and Objectives1.

2.

3.

4.

5.

6.

13 Agency Contact Details

14 Social Worker Name:

Position

Agency:

Address:

Telephone Number:

Fax Number:

E-mail Address:

15 Other Significant Professional’s Details Name:

Position

Agency:

Address:


Telephone Number:

Fax Number:

E-mail Address:

16 Referrer’s Details Name:

Position

Agency:

Address:

Telephone Number:

Fax Number:

E-mail Address:

17 Referral Documentation ProvidedLac or DOH Documents (inc Care Plan) Yes N/ACore Assessment ☐ ☐Individual health Plan ☐ ☐Individual Educational Plan ☐ ☐Personal Education Plan ☐ ☐List of Personal Belongings ☐ ☐Chronology ☐ ☐Placement 1&2 ☐ ☐Essential Information 1&2 ☐ ☐Integrated Children’s System (ICS) Docs ☐ ☐Medical Consent Card ☐ ☐Outdoor Education Consent ☐ ☐Statement of SEN ☐ ☐Pathway Plan ☐ ☐Other please specify e.g. YOT Documents, CAMHS assessments, risk assessments etc.

☐ ☐

Signed consent for School Placement (Wales) ☐ ☐


18 Funding- Authority Details Finance Contact Name:

Finance Contact Telephone Number:

Invoicing Address:

Special funding arrangements (i.e. any split between departments)

Any other information required to aid billing process ( e.g. purchase order numbers)

19 Any Additional Information

.

Bryn Melyn Care Ltd2 High Street DawleyTelford TF4 2ET

Tel: 01952 504715 or Mob: 07921 106

hhtp://ww.brynmelyncare.com


20 Pre-Admission Checklist (Please can you provide the following information or advise when the information will be made available. If the information is not available, please state this in the space provided).

Item Comments (Tick box for yes)

EDUCATION

Copy of the Statement ☐

Copy of School IEP’s ☐

Any school reports from head teacher or class teacher

☐

Any professionals reports (Ed, psych,PEP)

☐

Is additional support needed in class (hours/above statement)- if possible

☐

Outstanding issues in school ☐

Chronology ☐

LAC INFORMATION

LAC essential information forms 1&2 ☐

LAC Placement Plan 1&2 ☐

LAC Care Plan- current and proposed

☐

Minutes from the previous 2-3 review meetings and from meetings outlining the need for residential therapeutic care.

☐

Medical issues or statement of medical concerns

☐

Medical Consent form Signed ☐



Significant events ☐

Criminal activity ☐

Fire Risk Assessments/concerns ☐

Self-harming risk/concerns ☐

Risk Assessments (other) ☐

Other professional involvement if available

☐

Family history ☐

Young Person’s History ☐

GAL and Court reports if available ☐

Physical intervention consent form ☐

Core assessment ☐

RISK

A balanced view of risk and evidence is required in order to inform care managers.

Impact Assessment (BMC to complete) ☐

Risk to self ☐

Risk to others ☐

Misc.risks (pets, road, rivers etc.) ☐

OTHER INFORMATION

List prohibited contact ☐

Previous contact arrangements ☐

Proposed contact arrangements when In placement (contact agreement)

☐



THERAPY

Any therapy to date: ☐

Style: ☐

Type: ☐

Reports: ☐

Therapeutic assessment ☐

Psychological assessment ☐

Future needs ☐

FOR A MEADOWS PLACEMENT

Smoking policy sent ☐

Mobile phone policy sent ☐


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