Social Services Northern Ireland Fermanagh Help Message Board Referral Initial Assessment Record Social Services Form

REFERRAL AND INITIAL INFORMATION RECORD REFERRAL AND INITIAL INFORMATION RECORD SSD Case Numbers Date referral received Is the parent/carer aware of the referral? Yes n No n Re-Referral n Child/Young Person’s name, address and responsible LA Family name Forenames Dob Gender Address Postcode Tel. Current address if different from above Postcode Tel. SSD Team Responsible local authority Child/Young Person’s principal carers Name Relationship to child/young person Parental Responsibility Yes n No n Yes n No n Referred by Agency/rel. to child/young person Address Postcode Tel. Does referrer wish to remain anonymous Yes n No n Other household members (including non-family members) Surname Forename DoB SSD case number if appropriate Relationship to child Tick if also referred to SSD Significant family members who are not members of child’s household Name Name Relationship Relationship Address Address Tel. Tel. Child/young person’s religion Child/young person’s ethnicity: Caribbean n Indian n White British n White and n Chinese n Black Caribbean African n Pakistani n White Irish n White and n Any other n Black African ethnic group Any other n Bangladeshi n Any other n White and n Not given n Black background White background Asian Any other Asian background n Any other mixed background n If other, please specify Child’s first language Parent(s) first language Is an interpreter or signer required? Yes n No n Has this been arranged? Yes n No n Information on statutory status Yes No Please give details: Child/young person or other child(ren)/ Name Date(s) young person(s) in family is/has on a disability register n n Child/young person or other child(ren)/ Name Date(s) Category young person(s) in family is/has on a child protection register n n Child/young person or other family Name Date(s) member(s) has/have been looked after a local authority n n Other SSD cases associated with the child/young person Name Case No. Name Case No. Name Case No. Name Case No. Key agencies (please tick if currently working with the family) G.P. n Tel. H.V. n Tel. Nursery n Tel. E.W.O. n Tel. School n Tel. Police n Tel. Y.O.T. n Tel. Dentist n Tel. Community Mental Health n Tel. Community Paediatrician n Tel. School Nurse n Tel. Other n Tel. Reason for referral/request for services: Name of staff member completing this referral Signature Date Further action: Practice note: ensure this referral is collated with previous referrals or files Provision of information and advice n Referral to other agencies (please state which) n Initial assessment (to be completed within 7 working days) n No further action n Reason for Further Action Name of Team Manager Signature Date © Crown Copyright 2000 ISBN 0 11 322436 2 Document available

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We are indeed aware of Article 170: Privacy for children involved in certain proceedings. but also Section 62: Publication of material relating to legal proceedings (251.252.) Which means that nothing can be published that may identify any CHILD during court process yet; Council's can publish photographs and detailed profiles of children online in advertising them for adoption.

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