PRIVATE & CONFIDENTIAL

Not to be copied or shared without the prior permission of the author

Ref:Date:

SHORT BREAK REQUEST SUMMARY REPORT

To be attached to all CAF/Single Assessment documentation – detailing needs of child and family..

In order to support the ‘Tell it once approach’ please also ensure as much information as possible is gathered from current My Support Plan, EHC Plan/ statement or other assessments, prior to completing this form.

NAME: / DOB:
ADDRESS: / CONTACT DETAILS:
SCHOOL:
NAME OF PARENT/CARER:
CHILD’S LEGAL STATUS: / AGE:
HAS PARENTAL RESPONSIBILITY? YES/NO

AReason for referral

  • Detail the reason for the current referral

B Summary of Child’s Developmental Needs

  1. (name of child’s) General health
  • Any diagnosed medical condition?
  • Any sensory/physical disability?
  • What is impact of the above on child’s functioning?
  1. (name of child’s) Communication and Interaction Needs
  • Can the child communicate verbally
  • Does the child use sign language or communication aid? If so what?
  • Can the child communicate needs eg for food, drink
  1. (name of child’s) Social Emotional and Mental HealthNeeds (Behaviour)
  • Any specific behavioural difficulties?
  • Difference between home and school behaviour?
  • Able to play with other children?
  • Is sociable with other children?
  • Shows awareness of danger? (Inc strangers)
  1. (name of child’s) Perception of Self
  • How is their self esteem/self image?
  • What is social presentation like?
  1. (name of Child’s) Family and Social relationships
  • Any friends?
  • Relationship with parents?
  • Are parents separated? If so is contact maintained with both?
  • Relationships with siblings?
  1. (name of child’s) Self Care and Independence Skills
  • Can the child feed independently? Is s/he orally fed?
  • Is the child independently mobile?
  • Can the child take care of own toileting needs
  • Can the child dress/undress independently?
  1. (name of child’s) Education andLearning Needs
  • What is their level of learning? (SLD, MLD)
  • Is the child making progress at school?
  1. Any other relevant information re (name of child’s) developmental needs

OVERALL SUMMARY OF CHILD’S DEVELOPMENTAL NEEDS

(PLEASE TICK AS APPROPRIATE)

Capacity of the child to carry out all normal day-to-day activities is severely limited by their impairment/ needs / Capacity of the child to carry out all normal day-to-day activities is limited by their impairment/ needs / Capacity of the child to carry out most normal day-to-day activities is limited by their impairment/ needs / Capacity of the child to carry out severalnormal day-to-day activities is limited by their impairment/ needs / Capacity of the child to carry out some normal day-to-day activities is limited by their impairment/ needs

C. SUMMARY OF PARENTING CAPACITY

  1. Basic care ensuring (name of child’s) safety and protection
  • CAF/MSP/Single Assessment?
  • CP plan in place?
  • Any other relevant information?
  1. (name of child’s) Emotional warmth and stability
  • Is the family currently in a stable situation?
  • Any current barriers to the parents providing emotional warmth towards the child?
  • If the parents are currently separated or separating, what is the impact on the child?
  1. Guidance, boundaries and stimulation for (name of child)
  • Is the family able to put consistent boundaries in place to support the child’s behaviour?
  • Is the family able to put consistent provision in place to meet the child’s physical needs?
  • Is the family able to provide a consistent and appropriate level of stimulation?
  1. Any other relevant information re parenting capacity

OVERALL SUMMARY OF PARENTING CAPACITY (PLEASE TICK AS APPROPRIATE)

Capacity of parent/ carer to carry out all normal day-to-day activities is severely/ critically limited / Capacity of parent/ carer to carry out all normal day-to-day activities is limited / Capacity of parent/ carer to carry out mostnormal day-to-day activities is limited / Capacity of parent/ carer to carry out several normal day-to-day activities is limited / Capacity of parent/ carer to carry out somenormal day-to-day activities is limited

D. FAMILY AND ENVIRONMENTAL FACTORS

  1. Family history functioning and well being
  • Family structure including any siblings and their ages
  • Any relevant family medical conditions
  1. Wider family support
  • Brief history of service involvement
  • Description of family support network
  1. Housing employment and financial considerations
  • Description of family employment/Income(including DLA and any other benefits)
  • Does the family drive and have access to a car?
  • Is the child’s housing suited to his/her needs?
  1. Social and community elements
  • What support is the family currently accessing?
  • Does the child access social situations outside the family home - other than school?
  1. Any other relevant information re family and environmental factors?

OVERALL SUMMARY OF FAMILY AND ENVIRONMENTAL FACTORS

(PLEASE TICK AS APPROPRIATE)

Ability of the family to access alluniversal services and community resources is severely limited / Ability of the family to access alluniversal services and community resources is limited / Ability of the family to accessmostuniversal services and community resources is limited / Ability of the family to accessseveraluniversal services and community resources is limited / Ability of the family to accesssomeuniversal services and community resources is limited

E ADDITIONAL INFORMATION

  1. (name of child’s) views
  • What is the child’s view of the proposals?
  1. Family views
  • What are the family’s views of the proposals?
  1. Family Support to manage needs in future
  • What work is being completed to support the family to increase their capacity to meet these needs in the future?

FSummary of recommendations to meet (insert name)’s Needs:

  • Detail what you believe is required to meet current needs?

Amended by Fiona Law (Service Manager – Educational psychology and Assessment Service) and

Chris Lingard (Interim Service Manager – SENSS) 1.12.2015